Job Description

Senior Quality Assurance Officer – Medical Approval and Claims

About the job:

MedNet Egypt is one of the leading managed care service organizations that caters to healthcare needs. We are looking for a skilled Senior Quality Assurance Officer- L2 who will conduct standardized quality audits of claims and approvals to ensure accuracy, compliance, and timely resolution of findings. Perform detailed review, documentation, and escalation of audit results in accordance with the department’s SOP and QA framework.

Your Job:

• Extract data, sample claims / approvals, and distribute audit samples according to SOP guidelines.
• Perform detailed audits based on the audit checklist, document findings per service line, including decision validation, final category per invoice, root cause, financial impact, and corrective measure recommendations.
• Share initial audit findings with responsible departments, track department feedback, and re-evaluate claims as needed.
• Share audit findings with L1 Team, track department feedback, and re-evaluate cases as needed.
• Escalate unacknowledged items per SOP timelines.
• Escalate unacknowledged items or unmet SLAs as per escalation matrix and to line Manager(s).
• Participate in L1 and L2 calibration, finalize audit results, and align findings with respective teams.
• Identify trends in fraud, waste, and abuse from network providers or insured members and report to QA Management/FWA team.
• Contribute to system and process enhancements, including automation rules and provide regular feedback and action plan to Rule Engine team.
• Coach team members on policy and procedure updates, Workflows, regulatory updates, new packages, and coding (ICD/CPT) queries.
• Respond accurately and within SLA to queries from payers, providers, members, and internal stakeholders.
• Ensure continuous improvement of QA processes for claims / approvals audits, including tracking, reporting RCA findings and overpayment recoveries.

Your Profile:

• Bachelor’s degree in medicine, pharmacy & dentistry
• 2 years of experience in Claims/ Approvals processing or audit and reporting.
• Experience in the Insurance industry with Insurer/TPA in claims is a plus
• Computer literacy (MS Office, Excel, PowerPoint)
• Industry knowledge related to the local health services system is a plus
• Strong understanding of claim auditing, QA frameworks, and workflows.
• Analytical thinking and attention to detail
• Strong communication and documentation skills
• Good command of English