Claims & Medical Operations Specialist

GIG Gulf; Muscat; On-site; OMR 10,000 - 15,000; Full time

Job summary

A regional insurance provider in Oman seeks a Medical Insurance Processor to assess and evaluate medical claims, ensuring adherence to policies while providing excellent customer service. The ideal candidate will be Omani with a medical degree and experience in insurance processing, capable of handling client inquiries across various channels and contributing to operational excellence. Strong analytical and communication skills are essential for success in this role.

Qualifications

• Omani National.
• 1-2 years’ experience in Medical Insurance Process.
• 6 months to 1 year experience in handling calls.
• Will be required to work in shifts.
• Regional experience and working knowledge of healthcare regulations in Oman.

Responsibilities

• Adjudicate insurance pre-approvals in a timely manner.
• Attend calls from members and providers.
• Process direct billing claims accurately.
• Identify and report potentially fraudulent claims.

Skills

Strong communication (verbal & written)

Medical knowledge and terminology

Analytical skills

Customer-focused

Education

Medical Degree (Medical / Dental / Nursing / Pharmacy / Physiotherapy)

Job description

Overview

GIG Gulf (a Fairfax company) is part of the Gulf Insurance Group (GIG), the #1 largest regional composite insurer in the Middle East and North Africa, with presence in 12 markets. GIG Gulf is an ‘A’ rated regional insurer focused on regional growth, customer experience and digital transformation. Our workforce includes over 800 employees across 15 branches, serving more than 1 million customers, and we own a 50% stake in GIG Saudi.

Job purpose: To assess and evaluate preapproval requests and processing medical claims in terms of medical eligibility and policy terms; attend calls and meet client expectations by providing a world-class customer service experience. Respond to and liaise with GIG policyholders, insurance brokers and network providers in a professional and courteous manner.

Key Responsibilities

• Adjudicating and processing insurance pre-approvals (OP, IP, and Pharmacy [PBM]) in a timely and accurate manner following company policy terms and conditions and process guidelines. Process pre-approvals within the agreed TAT per line of business.
• Attend calls from members, brokers, providers, and clients within SLA.
• Attend calls from pharmacies for pre-approval of medications.
• Contribute to cost containment through GIG guidelines and proper medical adjudication.
• Assist team in customer care email management as required on an ad hoc basis.
• Involved in processing direct billing claims according to department requirements; review complex claims, decide on claim settlements, resolve issues or disputes, and ensure processing is accurate and compliant with policies and regulations.
• Communicate with providers and other departments via email and phone (claims registration, escalations, liaising with other departments, handling provider queries).
• Adhere to and comply with all applicable laws, regulations, and industry standards; conduct quality assurance audits and internal reviews and report to the line manager.
• Operational and technical responsibilities include: sound knowledge of medical and insurance guidelines; understanding Healthcare Platform to direct queries; knowledge of local regulations in Oman; decide on pre-approval based on medical necessity and international guidelines; report provider abuse if recurrent as part of cost-containment; respond to calls professionally to deliver world-class service; keep all files confidential; provide extraordinary service via phone, email and other channels.
• Take end-to-end ownership for resolution of all customer inquiries; manage queries to resolution; accurately maintain and update customer records in the management system; achieve targets for contact handling, turnaround times, quality, productivity.
• Receive and respond to inquiries related to healthcare policy benefits and claims from private or corporate clients/policyholders; oversee the claims processing workflow across direct billing and reimbursement departments; assign tasks, monitor progress and ensure efficient processing; conduct regular audits and quality checks, provide coaching and implement corrective actions as needed.
• Identify and report potentially fraudulent or suspicious claims; collaborate with FWA and NW departments and escalate to the line manager; work with NW team to maintain accurate provider information and ensure reimbursement according to negotiated rates.

Requirements

Essential:

• Omani National
• 1-2 years’ experience in Medical Insurance Process
• 6 months to 1 year experience in handling calls
• Medical Degree (Medical / Dental / Nursing / Pharmacy / Physiotherapy)
• Will be required to work in shifts
• Regional experience and working knowledge of healthcare regulations in Oman
• Medical knowledge, medical terminology, and computer handling skills
• Strong communication (verbal & written)

Desirable:

• Good analytical skills
• Customer-focused
• Ability to work effectively within a team
• Highly motivated and proactive
• Results-driven and solution-oriented