Medical Claims Officer

About the role

The Medical Claims Officer will join Walaa Cooperative Insurance’s medical insurance team in Saudi Arabia. You will be responsible for reviewing and adjudicating outpatient, inpatient, and reimbursement claims while ensuring compliance with policy terms and regulatory standards.

Key responsibilities

• Process and adjudicate medical claims, validating documentation, coding (ICD, SBS), and medical necessity.
• Ensure claims align with policy coverage, exclusions, limits, and contractual terms.
• Identify and flag potential overutilization, billing errors, duplicate or fraudulent claims.
• Support cost‑containment initiatives by reviewing high‑value claims and negotiating settlements.
• Maintain turnaround times within defined SLAs and prioritize urgent or high‑value cases.
• Coordinate with healthcare providers, internal medical approvals, and other departments to resolve missing or unclear information.
• Assist investigations of fraud, waste, and abuse by providing medical insights.

Required profile

• Bachelor’s degree in Medicine, Dental Surgery, or a related field.
• 1‑3 years of experience in medical insurance claims processing and auditing.
• Strong knowledge of Saudi Arabian insurance regulations (e.g., CCHI) and market practices.
• Excellent analytical, decision‑making, and attention‑to‑detail abilities.
• Proven time‑management skills to handle high volumes without compromising quality.

Required skills

• Claims management software
• Healthcare IT systems
• Claims processing
• Microsoft Office (Word, Excel, PowerPoint)