Roles & Responsibilities

• Prepare, maintain, and update insurance claim data and documentation as per insurance company requirements.
• Review and validate claim forms, prescriptions, invoices, and supporting documents to ensure compliance with insurer guidelines.
• Coordinate with pharmacists and relevant stakeholders to resolve claim discrepancies and obtain required documentation.
• Ensure timely claim processing and submission to minimize rejections and delays.
• Consolidate, reconcile, and submit monthly insurance claim reports to the Accounts Department.
• Process direct claim submissions through insurance portals such as Al Koot and QLM after obtaining necessary approvals.
• Coordinate with Front Office Executives for claim submissions to other insurance providers.
• Monitor claim status, follow up on pending claims, and manage rejections, corrections, and resubmissions.
• Maintain accurate records of submitted, approved, rejected, and pending claims for reporting and audit purposes.
• Verify ICD-10 and MOPH drug codes before claim submission to ensure accuracy and compliance.
• Maintain and update Table of Benefits (TOB) references for efficient claim processing and coding support.
• Generate periodic reports on claim performance, rejection trends, outstanding claims, and insurance metrics.
• Provide insurance-related support and guidance to pharmacists and internal teams.
• Stay updated on insurance policies, regulations, and newly added insurance providers to ensure compliance.
• Supervise and guide back-office coders, claims executives, and coordinators to maintain quality and efficiency.
• Manage insurance portal access credentials securely and ensure timely updates.
• Analyze rejection trends and recommend process improvements to enhance claim approval rates.
• Ensure confidentiality of patient information and adherence to company policies and regulatory requirements.