Claim Processor Medical Claims
Job Description Job Title: Claim Processor - Medical Claims (MBBS) Employment Type: Full-Time Location: Sharjah Job Summary The Claim Processor is responsible for reviewing, evaluating, and processing health insurance claims while ensuring compliance with policy terms, medical guidelines, and regulatory requirements. The role requires strong medical knowledge to assess diagnoses, treatments, procedures, and hospitalizations for claim adjudication. Key Responsibilities - Review and assess medical insurance claims for accuracy, completeness, and policy coverage. - Analyze medical records, discharge summaries, diagnostic reports, prescriptions, and treatment plans. - Verify the medical necessity and appropriateness of treatments, procedures, and hospital admissions. - Evaluate claims in accordance with policy terms, clinical guidelines, and company protocols. - Identify discrepancies, inconsistencies, potential fraud, abuse, or overutilization in submitted claims. - Coordinate with hospitals, clinics, healthcare providers, and internal teams to obtain additional medical information when required. - Approve, deny, or recommend modifications to claims based on medical and policy assessments. - Ensure claims are processed within defined turnaround times and quality standards. - Maintain accurate documentation and records of claim decisions. - Assist in medical audits, utilization reviews, and quality assurance activities. - Provide medical support and guidance to claims operations teams. Required Skills: - MBBS degree from a recognized medical institution. - Experience in Insurance or Fresh MBBS graduates may be considered. - Strong understanding of medical terminology, diagnosis, treatment protocols, and healthcare procedures. - Knowledge of health insurance policies, claim adjudication processes, and reimbursement methodologies. - Ability to interpret medical records and clinical documentation. - Strong analytical and decision-making skills. - Attention to detail and accuracy. - Excellent written and verbal communication skills. - Proficiency in MS Office and claims management systems.
