RCM - Medical Claims Specialist

About the role

Join My Clinic, a leading multispecialty outpatient provider in Saudi Arabia, as a Medical Claims Specialist within the Revenue Cycle Management (RCM) team. You will support Medical Operations by reviewing and validating insurance claims to ensure medical necessity, documentation completeness, and compliance with payer requirements.

Key responsibilities

• Perform detailed clinical review and validation of medical claims prior to submission, confirming accuracy, completeness, and claim readiness.
• Validate medical necessity, diagnoses, investigations, procedures, medications, and other billed services against the patient record and plan of care.
• Review claim documentation for completeness and consistency, including physician notes, orders, results, and required attachments.
• Identify and flag clinical, coding, documentation, utilization, duplicate‑service, unbundling, eligibility, and payer‑rule risks that could lead to rejections or write‑offs.
• Coordinate with physicians, Medical Operations, Pre‑Authorization, Claims/Billing, and other teams to resolve discrepancies and complete corrections within submission timelines.
• Analyze rejected or deducted claims from a clinical perspective, determine root causes, support rework/resubmission, and recommend preventive actions.
• Monitor recurring claim issues and rejection trends, providing feedback for education or process improvements.
• Support claim quality audits, payer queries, reconciliation activities, and preparation of clinical justification when required.

Required profile

• Bachelor’s degree in medicine (MBBS/MD), Pharm D, Biology, microbiology, Chemistry, or equivalent clinical qualification.
• Minimum 2 years of experience in healthcare, medical insurance, claims review, utilization review, or Revenue Cycle Management, preferably in a high‑volume outpatient setting.

Required skills

• Medical coding
• Claims management
• Revenue Cycle Management