Medical Claim jobs

The Medical Claims Auditor is responsible for reviewing and auditing medical insurance claims to ensure accuracy, compliance with policy terms, medical necessity, coding standards, and applicable regulatory requirements. The role involves identifying discrepancies, overpayments, inappropriate billing, and potential fraud while ensuring claims are processed accurately and efficiently.

Key Responsibilities:

• Conduct detailed audits of medical insurance claims, including inpatient and outpatient claims.
• Review medical bills, treatment records, diagnosis, procedures, and supporting documentation.
• Verify claims against policy benefits, exclusions, limits, and contractual terms.
• Assess medical necessity, appropriateness of treatment, and utilization of healthcare services.
• Review medical coding, billing practices, and tariff application for accuracy.
• Identify duplicate claims, overbilling, incorrect coding, and potential fraudulent activities.
• Investigate claim discrepancies and coordinate with claims teams, healthcare providers, and insurance companies.
• Recommend claim adjustments, recoveries, or rejections where applicable.
• Conduct pre-payment and post-payment audits to identify financial and operational risks.
• Prepare audit reports highlighting findings, discrepancies, financial impact, and recommendations.
• Monitor recurring errors and recommend process improvements to reduce claim leakage.
• Ensure compliance with internal policies, insurance regulations, and applicable healthcare standards.
• Support internal and external audits and provide required documentation.
• Maintain accurate records of audit findings and corrective actions.
• Provide guidance and feedback to claims processing teams on identified issues.

Requirement:-

• UAE experience required.
• Immediate Joining Preferred

Work Location: In person