Job Description

Role Purpose

• Evaluate medical necessity and consistency of diagnosis, procedures and drug codes and descriptions stated on the dental claims, according to accepted dental coding rules and guidelines
• Process (re-)submission dental claims according to expected daily target, quality, and other KPIs
• Ensure accurate application of contractual prices/discounts, schedule & correct allocation of benefits, collection of deductibles & co-payments, observance of policy limits, and adherence to claim submission protocols
• Assist the Supervisor in organising and monitoring execution of the daily tasks of the team
• Occasionally assist supervisors in reviewing claims by following certain auditing criteria, guidelines and applying the high costs authority matrix when needed
• Escalate any providers’ observations to the supervisor to improve the quality of provider claims
• Contribute to developing, updating and implementing guidelines for evaluation & processing of Dental claims, and policies, procedures and work-instructions related to Dental claims review and processing
• Assist in providing training for the new joiners and answer common processing queries.
• Assist in monitoring and providing training to improve the technical, insurance and medical skills and knowledge for team members to manage the daily duties and responsibilities, improve performance and efficiency, fulfill special tasks and achieve set targets
• Gather relevant information to clearly describe & properly escalate work related issues to supervisors
• Consistently, efficiently and effectively work on achieving the daily targets
• Ensure that business decisions and processes are documented in a professional way and the communication requirements are being adhered to in a timely and professional manner
• Deliver high quality customer service and respect medical and work ethics at all times
• Report fraud and abuse cases to MIAD department according to set policies and procedures

Key Requirements and Qualifications

• 3+ years of experience in any of the medical units of a health insurance company or third party administrator (TPA), minimum 1 year of which experience as Dental Review Officer or equivalent role
• Bachelor’s degree in Dental Surgery or Doctor of Dental Surgery

Skills and Competencies

• Good command of written and spoken English; knowledge of Arabic language is an advantage
• Good analytical, execution, problem solving and decision-making skills
• Proactive and results oriented whilst ensuring high quality of work
• Advanced level of customer service orientation and professionalism in all interactions
• Good knowledge of health insurance concepts