Senior Medical Claims Officer

The Senior Medical Claims Officer leads the claims team to control and monitor total medical expenditure for projects, ensuring all invoices and claims from providers are verified and properly recorded. The role involves managing the medical claims review process, supervising coordinators, and ensuring compliance with policies and laws.

Responsibilities

• Lead the medical claim structure autonomous from the medical team responsible for service delivery and case management
• Manage medical claims reviewing process and provide reports related to cost control and planning
• Manage and supervise the team of medical claims coordinators reviewing claims submitted by hospitals
• Approve medical reports, requirements, and documents from health providers
• Review price lists and create comparisons among providers during contracting phase
• Review and sign off final report for all claims with comments and deductions
• Set corrective actions for medical documentation required for claims settlement with medical team and hospitals
• Coordinate with finance team on medical claims review, payment approval and processing
• Monitor status of referrals, commitments, and claims up to project closure
• Ensure compliance of medical claims with Egyptian law, SCI policies, and donor compliance
• Work with health program manager on monthly spending and forecasted reports
• Lead communication channels with health service providers regarding claims and deductions
• Provide cost-controlling support including forecasting and variation reporting
• Review and sign off all medical cash payments for beneficiaries
• Improve medical claims reports and documentation
• Provide technical support and guidance to health service providers to increase accuracy in medical reports
• Participate in medical audits to enhance claims documentation
• Ensure timeliness and completeness of claims reporting process
• Carry out additional tasks as requested by line managers

Requirements

• Bachelor of medicine is required
• Certificate in auditing, cost control is highly desirable
• Bachelor’s degree in medicine and surgery BSC is must
• 5-7 years’ experience in medical claims auditing, project cost planning and reporting
• Experience in healthcare setting is highly desirable
• High computer skills on MS office programs especially MS Excel
• Demonstrate strong interpersonal, communication and presentation skills
• Strong analytical and problem-solving skills and meticulous
• Possess good project background and technical writing ability and skills
• Mature, proactive, resourceful and hands-on with good initiative
• Good command in English, both verbal and written, required

Skills

• Medical Claims Auditing
• Project cost management
• Cost Control
• Healthcare Experience
• MS Excel
• Medical Claims Review
• Invoice Verification
• Compliance Monitoring
• Technical Writing
• Project Reporting
• Interpersonal Skills
• Presentation Skills
• Analytical Skills
• Problem Solving
• Medical Knowledge
• Claims Management

Languages

English