Job Description

MedNet Egypt is one of the leading managed care service organizations that cater to healthcare needs. We are looking for skilled Senior Medical Reviewer – Reconciliation who will be responsible for clinical review, validation, and reconciliation of medical claims to ensure accuracy, medical necessity, policy compliance, and adherence to regulatory and contractual requirements while maintaining high service quality.

Your Job:

• Maintain TAT of reconciliation claims, Quality of reviewing, and other Key performance indicators set by the line manager.
• Ensure accurate application of policies and procedures for reconciliation, correct allocation of benefits, collection of deductibles/copayments, discount, and adherence to claims submission protocols.
• Review inpatient and outpatient claims rejected at initial/ resubmission levels for Medical and/or technical reasons.
• Validate diagnosis and procedures against clinical guidelines and insurance policy terms.
• Review high-value, complex, and disputed claims prior to reconciliation or settlement.
• Perform medical and technical reviews related to reconciliation of claims, identifying discrepancies related to coding, tariffs, benefit limits, or clinical justification for supporting the Reconciliation team in account closures.
• Consistently, efficiently and effectively work to achieve the daily targets and the initiatives.

Your Profile:

• Bachelor’s degree in medicine, pharmacy & dentistry or related fields.
• Minimum 3- 4 years of experience in Reconciliation claims review in insurance industry of UAE.
• Understanding of ICD-10, CPT, DRG.
• Computer literate and excellent knowledge of Microsoft applications
• Excellent communication and interpersonal skills
• Good command of written and spoken English language, Arabic knowledge is an added advantage
• Good analytical, planning, execution and conflict solving skills
• Basic knowledge of relational databases
• Time management and attention to details