Job Description

MedNet Egypt is one of the leading managed care service organizations that cater to healthcare needs. We are looking for skilled Senior Medical Officer – Rule Engine who will be responsible for managing, configuring, reviewing, testing, and continuously update automation and rule engines supporting Approvals and Claims automation, FWA detection, medical rules, and business requirement rules. Ensure rules are accurate, compliant, data-driven, and aligned with audit objectives, enabling high savings and recovery potentials, measurable outcomes, and productivity

Your Job:

• Review, maintain, and optimize FWA, medical, and business rules within the Medical Rule Engine.
• Manage rule logic covering fraud, abuse, waste scenarios, clinical appropriateness, benefit coverage, coding, and policy compliance.
• Conduct end-to-end rule testing, UAT, and validation, including logic, threshold, and performance checks.
• Ensure complete governance documentation for rule logic, assumptions, testing, approvals, and audit trails.
• Monitor and evaluate rule performance using KPIs such as accuracy, hit rate, savings/recovery impact, and claims correction.
• Identify and implement automation opportunities to enhance productivity and reduce manual interventions.
• Collaborate with FWA, QA, Claims, Approvals, IT, Network, Production, and operational teams on system and process enhancements.
• Support calibration of QA and FWA findings and align automation outputs with audit and medical objectives.
• Coach and support colleagues on rule engine logic, system functionality, and automation best practices.
• Plan, map, review, and quality-assure rule data prior to system deployment in both beta and live environments.
• Define, execute, and validate testing scenarios for rules, tasks, and technical developments across the rule engine and supporting systems.
• Ensure rule development and maintenance comply with governance frameworks and stakeholder communication protocols.
• Coordinate stakeholder meetings, manage progress and maintenance reporting, and support delivery of medical review automation initiatives.

Your Profile:

• Bachelor’s degree in medicine, pharmacy & dentistry or related fields.
• 2-3 years of experience in the Health Insurance industry with Insurer/TPA specifically with experience in automation, rule engine, audit, claims and approvals automation.
• Industry knowledge related to the local health services system is a plus
• Strong understanding of claim auditing, QA frameworks, and workflows, automation and rules configuration.
• Strong understanding of rule engines, automation logic, and claims systems.
• Knowledge of medical coding (ICD, CPT) and clinical/claims workflows
• Strong analytical thinking and attention to details
• Strong documentation and communication skills
• Good command of English and computer literacy