Job Description

1. Perform detailed clinical review and validation of medical claims prior to submission to ensure accuracy, completeness, and claim readiness.
2. Validate medical necessity, diagnosis, investigations, procedures, medications, and other billed services against the patient medical record and documented plan of care.
3. Review claim documentation for completeness and consistency, including physician notes, reports, orders, results, supporting documents, and required attachments.
4. Identify clinical, coding, documentation, utilization, duplicate-service, unbundling, approval, eligibility, and payer-rule risks that may lead to rejection, deduction, or write-off.
5. Ensure consistency between services rendered, approvals obtained, quantities/sessions, diagnosis and procedure coding, and billed claim lines before final submission.
6. Coordinate with physicians, Medical Operations, Pre-Authorization, Claims/Billing, Operations, and other relevant teams to clarify discrepancies and complete required corrections within submission timelines.
7. Review rejected or deducted claims from a clinical perspective, identify root causes, support rework/resubmission where applicable, and recommend corrective and preventive actions to reduce recurrence.
8. Monitor recurring claim issues and rejection trends, provide feedback to the Medical Operations Lead, and support targeted education or process improvements for clinical and operational teams.
9. Support claim quality audits, payer queries, reconciliation activities, and documentation requests, including preparation of clinical justification and supporting evidence when required.
10. Support new branches, new services, payer activations, and increasing claim volumes by applying standardized medical claim validation processes and escalating material risks promptly.
11. Perform other professional duties as assigned by the Line Manager.

Education / Professional Qualifications:

1. Education Degree (Required): Bachelor’s degree in medicine (MBBS/MD), Pharm D, Biology, microbiology, Chemistry, or equivalent medical\clinical qualification.
2. Years of Experience (Required): Minimum 2 years of experience in healthcare, medical insurance, claims review, utilization review, or Revenue Cycle Management; experience in a high-volume outpatient setting is preferred.
3. License: (optional) Valid Saudi Commission for Health Specialties (SCFHS) classification/registration, where applicable to the professional qualification.
4. Professional Certification (Optional): Certification or formal training in medical coding, health insurance, claims management, or Revenue Cycle Management is preferred.

Benefits found in job post

Medical insurance

Requirements added by the job poster

• Doctor of Medicine