Head of medical and life
private company
Total years of experience :3 years, 3 Months
Job Responsibilities:
Reimbursement:
• Evaluating all the reimbursement claims overseas as well as local as per the policy terms and conditions with the best possible reasonable and customary rates
• Verifying all the original documents and reimburse as per the policy.
• Getting surgery charges as well as procedure charges from UAE based hospital as well as overseas hospital to compare rates.
• Rejecting treatment, tests, drugs, appliances, equipments and procedures, which are not covered by the policies and also not required for the case as per the standard exclusion.
• Communicating with clients as well as providers (hospitals), brokers, TPA and insured companies.
• Involved with all the correspondence between the clients and the insurance company regarding the client’s inquiry for the treatment and the policy benefits and all the denial cases.
Claim Processing:
• Supervising assessment of IP/ OP claims.
• Monitoring the overall claims assessment each day.
• Monitoring of all rejections and reconciliation of claims
Networks:
• Review the price lists of the medical providers and negotiating with the health provider for the best rates.
• Preparing the Contract for the medical providers
• Meeting with the medical providers for the reconciliation
• Addition and deletion of the doctors for different medical centers in the network.
Approvals:
• Assessing medical IP/OP request and give authorization.
• Determination of medical necessity of treatment received against diagnosis.
• Monitors work related injuries claims/maternity/palliative/pre-existing/chronic medical cases and deductible net procedure/claims.