Senior Executive Manager - Claims Reimbursement
Job Description
Leading a team of experienced medical reimbursement claims medical professionals, ensuring compliance with healthcare regulations, optimizing revenue cycles, and resolving complex reimbursement issues, establishes advanced communications with Sales and Regulatory compliance teams as well as monitoring Operational KPIs, improving quality decisions, Reimbursement claims utilization, ensuring appropriate interventions and flexibilities applied to improve NPS scores. Managing costs, affordability opportunities, initiatives and informatics and provide senior leadership with information and tools for strategic decision making and planning
Compliance and Regulatory Oversight
Ensure compliance with governmental and payer-specific regulations related to claims reimbursement. Stay current with regulatory changes, payer policies, and industry best practices to maintain compliance and improve reimbursement processes. Prepare and present reports on claims and reimbursement performance to senior leadership
Operational Capabilities
Oversee the daily operations of the claims processing and reimbursement team, ensuring timely and accurate claim submission and follow-up. Monitor and manage the entire claims lifecycle, from initial submission through final payment, ensuring claims are processed in compliance with payer / Policyholder guidelines. Identify and address issues that cause claim denials or underpayments, working with internal and external stakeholders to resolve them efficiently. Attract, develop, and retain talent while making sure that people with the right skills and motivations are in the right place Recommend analytical options, and alternate approach if needed, make independent analytical decisions, summarize, and present findings to executives. Contribute to establishing medical and adjudication guidelines, approaches, templates, and standards for the whole department. Ability to effectively set priorities amongst competing and challenging demands and assess its business criticality and link to the overall strategy, and efficiently resolves conflicting priorities with proper resources allocation (time, human, system). Assure maximum level of consistency and develop new validation and verification approaches to assure the accuracy of the results especially in the new areas and first time done work
Reimbursement Optimization & Digital Transformation
Develop strategies to optimize reimbursement rates and minimize denials, delays, or underpayments. Track and analyze reimbursement trends and provide actionable insights to improve claim outcomes. Collaborate with the billing and coding departments to ensure accurate coding and maximize reimbursements Research, identify, innovate & implement new operational and medical guidelines, facilitate medical cost management, alternative pricing strategies and benchmarks with constant measuring of the impact of proposed initiatives Collaborate with the different business units and functions in order to execute the assigned objectives related to Reimbursement projects and digital enhancements, transformations and implementations, and advance automatic adjudication capabilities and improve accuracy of decisions
Cross functional collaboration
Maintain relationships with and provide reporting & analytical support to business units and support cross-functional projects and requests including PR, compliance, HR, finance, Sales , clinical governance, and all operations units Enhance and maintain effective communication channels with the different stakeholders to well explain the output of the analytical work and transform very complex topics and data to a simple piece of info for easy and efficient decision making. Lead effective and smooth process flow of internal and external customer inquiries, complaints and requests and successfully resolve issues. Serve as reference lead for mega clients engagements and finalize all critical reimbursement issues & projects and initiatives within the set timelines
Medical Quality
Own the process of monitoring medical quality decisions across all reimbursement activities such as approval and rejection patterns and variations, provider utilization and customer cost trends and medical conditions as well as members behavior and various benefits utilization, potential Fraud combating with ability to run analysis and or focus on one or group of mega clients such as SABIC or ARAMCO. Manage the execution of quality activities and initiatives of quality improvement to provide senior leadership with information and tools for strategic decision making and planning regarding all potential quality improevment areas, that may significantly improve customer satisfaction, NPS and cost on short term and long term perspectives Provide information about various trends, initiatives being taken in operations and monitor the progress against each initiative and exceptions that require actions. Handle difficult and out of the norm or brand-new adjudication and Quality related problems either technical, and or variable encountered business situations that constantly require adaptation or development of new solution through analytical, creative & innovative thinking
Business opportunities
Identify and quantify potential business waste for abnormal or wrong Reimbursement claims handling behavior from member or user perspective. Identify and eliminate inefficiencies to create a portfolio of work leading to savings. Share savings opportunities from recoveries or prevention Validate savings before and after the executed actions by measuring the realized impact of the cost management activities Develop and review terms with cross functional departments and SLA. Create and implement new templates for price Benchmarking comparison and its impact studies and help integrate the automatic benchmarking new logics and protocols
Skills
Expert level with comprehensive and deep medical, commercial, technical and business knowledge combined with diverse and ultimate understanding of concepts, best practices and strategic direction Standard skill level with MS Excel and PowerPoint
Education
Bachelor's degree preferably in Business, Operation Management or Industrial Engineering
Job Location Jeddah , Saudi Arabia Job Role Management
