Medical Rules - Senior Manager (KSA)

Medical Rules - Senior Manager

Role Summary: 

Responsible for managing the product image and its development though client Interface by connecting Content and Business teams (BDU) simultaneously.

• Ensuring and supporting the development for rules content by providing support to internal team by reviewing, guiding, and validating the activities performed in the same regard.
• Reviewing data analytics and extracting insights based on market payers, regulator protocols, claims denial trends and users feedback analysis is also a part of the role being performed.
• To ensure adherence to market billing standards and protocols, the Medical Rules Senior Manager will be expected to work closely with stakeholders like payers, regulators and healthcare providers, revenue cycle departments to analyze coding/billing issues to be compliant with regulatory policies or denials with payers in market of KSA

Primary Responsibilities:

1. Role act as a bridge between internal THYNK product team and the management to communicate the vision and related development of the product.

2. Partnering with existing and potential clients to bring the vision for update to THYNK product team.

3. Liaising with team regularly and reviewing the activities to support best in interest of the vision of the management.

4. Developing on functionalities that can best support product to groom as per market practice.

5. Should be able to work well under pressure and simultaneous reporting to multiple lines of management.

6. Monthly validating with analysis team and review of claim remittance reports across all the payers and simultaneous provision of feedback suggesting updates for the rule engine thereby decreasing denial trends for the clients and maximizing remittance output.

7. Regular analysis and review of bypass reports containing feedback from end users to improve the rules logic, quality and accuracy of validation analysis and review of bypass reports containing feedback from end users to improve the rules logic, quality and accuracy of validation outcomes and optimizing end user experience.

8. Reviewing with internal teams clients historical denial reports establishing their trend analysis and target rules content profile to address their revenue integrity.

9. Apply effective communication skills (written and spoken) to communicate with all parties internal and external analyzing market insights and best market practice to produce accurate representation of the issues and the proposed solutions in the form of Rules Content definitions.

Job Requirements:

1. Minimum 10 years experience in the claim adjudication lifecycle and Insurance Payer or TPA is a must.

2. Previous work experience with Data Analytics packages such as Power BI will be preferred.

3. Excellent Analytical skills and an eye for detail is a must.

4. Understanding of insurance adjudication guidelines and protocols in a way to comprehend best to enrich KSA Medical Rules repository.

5. Recognized Professional Certification in Medical Coding will be a plus but not mandatory.

6. Should be well versed in KSA local market regulations and claims adjudication protocols.

7. Excellent verbal/written communication and presentation skills.

8. Proficiency in Healthcare Information Systems

9. Medical training as Doctor/Nurse/Pharmacist is highly desirable.

10. Certifications in Insurance and project management is highly desirable