Manager - Medical Claims

Tawuniya Insurance Company; Riyadh; On-site; SAR 89,000 - 134,000; Full time

Job summary

Tawuniya Insurance Company in Riyadh is seeking a qualified medical claims professional to process and evaluate medical claims accurately, ensuring adherence to coverage scope, provider contracts, and CHI/IA regulatory requirements. You will support data-driven claims management and participate in quality initiatives.

Join a team focused on timely processing, regulatory compliance, and continuous improvement, contributing to high-quality healthcare claim outcomes in a dynamic insurance

Qualifications

• MBBS degree required; Master degree is a plus.
• 1 year of experience in medical field.
• 4–5 years of experience in insurance industry, preferably medical claims.

Responsibilities

• Process assigned claims from creation through closing with agreed turnaround times.
• Ensure adjudication decisions comply with CCHI regulations, Insurance Authority requirements and Tawuniya policy.
• Review internal quality-review findings and implement corrective actions.
• Provide data-driven claims management support and participate in VBHC/DRG/PHM initiatives.
• Deliver KPIs and contribute to continuous improvement through Kaizen initiatives.

Skills

Medical claims knowledge

Regulatory awareness

Education

MBBS degree

Master degree

Job description

Process and evaluate all assigned medical claims efficiently and accurately, in accordance with the scope of coverage, provider contracts, and CHI/ IA regulatory requirements, while consistently meeting quality and turnaround-time standards.

Key Accountabilities:

• Apply Claims Department policies, procedures, and quality standards.
• Process assigned claims with efficiency, maintaining agreed TAT and SLA for all batches, from creation through closing.
• Handle internal and external email communications professionally, following email etiquette and agreed SLAs.
• Ensure all adjudication decisions comply with CCHI regulations, Insurance Authority requirements, and Tawuniya internal policy.
• Review internal quality-review findings, address identified gaps, and implement agreed corrective actions.
• Contribute to the training and development of claims staff by sharing medical knowledge and processing guidelines.
• Provide structured feedback on system limitations, operational process gaps, and improvement opportunities.
• Support data-driven claims management and healthcare value initiatives, including VBHC, DRG and PHM to identify utilization trends, improve quality and appropriateness of care, optimize healthcare costs and support continuous improvement.
• Provide medical claims data analysis to identify utilization patterns, cost drivers, abnormal trends and potential areas of leakage or overutilization.
• Deliver assigned KPIs and drive continuous improvement through quarterly Kaizen initiatives and OPLs.
• Pursue individual technical, personal, and medical skills development against the agreed capability-building plan.

Qualifications, Experience & Skills:

• University degree in MBBS; A Master degree is a plus.
• 1 year of experience in medical field.
• 4 - 5 years of experience in insurance industry preferably in medical claims.