Assistant Manager- Claims Doctor

Rozeegpt; Karachi Division; On-site; PKR 1,200,000 - 2,000,000; Full time

Job summary

EFU Life Assurance Ltd. is seeking an Assistant Manager- Claims Doctor with MBBS and PMDC registration to review and adjudicate medical claims. This role requires strong medical knowledge, ICD-10 coding proficiency, and meticulous evaluation of documentation to ensure policy compliance.

The ideal candidate will work closely with the claims processing team to ensure accurate, timely decision-making while upholding confidentiality and regulatory standards.

Qualifications

• MBBS degree with valid PMDC registration.
• Strong knowledge of ICD-10 coding and medical terminology.
• Experience with medical claims processing and regulatory guidelines.

Responsibilities

• Examine and evaluate medical claims by reviewing clinical documents, treatment protocols, and diagnostic information.
• Apply ICD-10 coding and billing expertise to classify and process claims accurately.
• Assess claims for eligibility, validity, and alignment with health insurance policies.
• Detect inconsistencies, discrepancies, or potential fraud in medical documentation and claims.
• Collaborate with providers, insurers, and internal teams to clarify claim details and resolve issues.
• Keep up-to-date with clinical procedures, coding changes, and healthcare regulations related to claims.

Skills

ICD-10 coding

Medical claims processing

Medical terminology

Regulatory compliance

Education

MBBS degree

PMDC registration

Job description

EFU Life Assurance Ltd. is seeking an Assistant Manager- Claims Doctor to join our team. This role requires a medical professional with an MBBS degree and valid PMDC registration, possessing a strong understanding of medical terminology, clinical procedures, and treatment protocols. The ideal candidate will be responsible for reviewing and assessing medical claims, diagnoses, treatment plans, and relevant documentation to ensure accuracy and compliance with health insurance policies. This position demands meticulous attention to detail to identify inconsistencies, medical discrepancies, and potential risks related to claims.The Assistant Manager- Claims Doctor works closely with the claims processing department to facilitate efficient and accurate medical claims adjudication. Although this role does not involve managing a team, it plays a key function in supporting the decision-making process and ensuring that all claims meet regulatory and company standards. The candidate must demonstrate excellent analytical skills and in-depth knowledge of medical coding systems like ICD-10 coding, as well as proficiency in medical billing and healthcare claims processing. The position offers an opportunity to contribute significantly to the quality and integrity of EFU Life Assurance Ltd.'s claims assessment process.

Responsibilities

• Examine and evaluate medical claims by reviewing supporting clinical documents, treatment protocols, and diagnostic information.
• Apply expertise in medical coding and billing, including ICD-10, to ensure accurate classification and processing of claims.
• Assess claims in accordance with company policies, health insurance guidelines, and regulatory requirements to verify eligibility and validity.
• Detect and report inconsistencies, discrepancies, or fraud indicators in medical documentation and claims.
• Collaborate with healthcare providers, insurance representatives, and internal departments to clarify claim details and resolve discrepancies.
• Maintain up-to-date knowledge of clinical procedures, medical terminology, and changes in healthcare regulations relevant to claims assessment.
• Provide expert medical input to support claim adjudication and decision-making processes.
• Prepare detailed analysis reports on claim assessments for management review as required.
• Support continuous improvement initiatives to enhance claims processing accuracy and efficiency.
• Ensure compliance with confidentiality and data protection policies related to patient medical information.