Assistant Manager - Claims Doctor

Szabist Isb; Karachi Division; On-site; PKR 90,000 - 130,000; Full time

Job summary

EFU Life Assurance Ltd. seeks an Assistant Manager - Claims Doctor to join the medical claims team. The ideal candidate holds an MBBS and has at least two years' experience in medical claims or insurance.

Requires deep knowledge of medical terminology, ICD-10 coding, and clinical documentation review to evaluate claims accurately. Must work independently with strong analytical and decision-making skills and collaborate with internal departments to comply with policies and standards.

Qualifications

• MBBS qualification with at least two years' experience in medical claims or insurance.
• Expertise in medical terminology, ICD-10 coding, and reviewing clinical documentation.
• Ability to work independently with strong analytical and decision-making skills.
• Collaborate with internal departments to support claims adjudication and compliance.

Responsibilities

• Review and analyze medical claims to verify accuracy against policy terms.
• Assess clinical documentation and ICD-10 coding for compliance with standards.
• Evaluate medical necessity and appropriateness of claimed treatments.
• Interpret medical terminology and clinical reports for accurate reviews.
• Collaborate with claims teams to clarify medical information and resolve discrepancies.
• Provide expert advice on complex medical claims issues and improve processes.
• Ensure assessments are thorough and completed within timeframes.
• Maintain up-to-date knowledge of coding standards and policies.
• Prepare detailed reports and documentation related to claims assessments.

Skills

Medical terminology

Medical coding

Clinical documentation review

Analytical skills

Decision-making

Education

MBBS

Tools

ICD-10 coding

Job description

EFU Life Assurance Ltd. seeks a diligent and knowledgeable Assistant Manager - Claims Doctor to join our medical claims team. The ideal candidate holds an MBBS qualification and possesses at least two years of experience, preferably in medical claims or insurance. This role demands profound expertise in medical terminology, medical coding including ICD-10, and clinical documentation review to ensure accurate evaluation of medical claims. The professional in this position works independently, demonstrating strong analytical and decision-making skills to assess medical documents thoroughly and make informed decisions that align with company policies and medical standards.The Assistant Manager - Claims Doctor plays a critical role in enhancing the claims processing workflow by meticulously verifying clinical details of submitted claims against insurance policies and medical protocols. This position requires a detail-oriented individual with the capability to interpret complex medical records and coding systems. While this role does not involve managing a team, it requires effective collaboration with internal departments to support the claims adjudication process and ensure compliance with regulatory and organizational guidelines.

Responsibilities

• Review and analyze medical claims to verify accuracy and validity based on medical documentation and insurance policy terms.
• Assess clinical documentation and medical coding, including ICD-10, to ensure compliance with established medical and insurance standards.
• Evaluate the medical necessity and appropriateness of treatments and procedures claimed, ensuring alignment with medical guidelines.
• Interpret medical terminology and clinical reports for accurate claims review and resolution.
• Collaborate with claims processing teams to clarify medical information and resolve discrepancies.
• Provide expert advice on complex medical claims issues and contribute to improving claims adjudication processes.
• Ensure claims assessments are thorough, accurate, and completed within designated timeframes.
• Maintain up-to-date knowledge of medical coding standards and insurance policies relevant to claims evaluation.
• Support compliance efforts by adhering to legal, regulatory, and ethical standards in claims review.
• Prepare detailed reports and documentation related to claim assessments and decisions.