Senior Manager - Medical Claims

Tawuniya; Riyadh; On-site; SAR 300,000 - 500,000; Full time

Job summary

Tawuniya is seeking a Lead, Medical Claims to steer the claims adjudication team, ensure compliant and timely processing, and drive cost-optimisation and value-based healthcare initiatives. You will guide improvements, mentor staff, and collaborate with stakeholders to uphold quality of care and operational performance.

Ideal candidate has 6+ years in health insurance/medical claims, with a medical background and postgraduate management qualification being a plus.

Qualifications

• Minimum 6 years of experience in Health Insurance, preferably in medical claims.
• 2 years of experience in the medical field.

Responsibilities

• Lead the Medical Claims team to deliver accurate, compliant adjudication.
• Drive timely claims processing and cost optimization initiatives.
• Coordinate workload planning and performance management.
• Ensure adherence to policies, procedures and quality standards.
• Communicate with stakeholders to resolve issues and maintain operations.
• Identify opportunities for process improvements and automation.
• Support VBHC, DRG and PHM initiatives to optimize care quality and costs.
• Coach and train team members to achieve targets.

Skills

Medical field experience

Health Insurance/Medical claims

Education

Bachelor of Medicine and Surgery

Postgraduate management degree (a plus)

Job description

Lead the Medical Claims team to deliver accurate, compliant, and timely claims adjudication, while driving continuous improvement, data-driven cost optimization, and value-based healthcare initiatives that strengthen quality of care and operational performance.

Key Accountabilities:

• Ensure the effective implementation and consistent application of Medical Claims Department policies, procedures, work instructions, and quality standards.
• Plan, allocate, and prioritize workloads across the Medical Claims team based on claim volumes, complexity, business priorities, employee capabilities and available resources to deliver operational targets.
• Manage team performance through clear objective setting, regular performance monitoring, structured feedback, and timely intervention to address productivity, quality, and TAT gaps.
• Maintain effective communication with stakeholder to facilitate timely issue resolution, minimize operational disruptions, and ensure continuity of claims processing activities.
• Ensure all adjudication decisions comply with CCHI regulations, Insurance Authority requirements, benefits structure and Tawuniya internal policy.
• Lead continuous improvement initiatives to address root causes, reduce processing errors, eliminate waste and improve team capabilities.
• Coach and provide on-the-job training to team members who require additional support to achieve defined processing targets.
• Provide structured feedback and recommendations to support system enhancements, process redesign, automation opportunities and improved claims processing accuracy and efficiency.
• 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.

Qualifications & Experience:

• Bachelor of Medicine and Surgery; Post Graduate Management degree is a plus.
• 2 years of experience in medical field.
• Minimum 6 years of experience in Health Insurance preferably in medical claims.