صيدليات النهدي تعلن عن وظيفة أخصائي أول تميز فاعلي الدفع في جدة

Develop and manage the excellence deployment for all payer operation and claim requirements in line with regulator policies and ensure proper collaboration with Nahdi departments to ensure the best outcomes via established SLA & SOPs.
Support and facilitate the development of long-lasting relationships with key accounts in the health insurance market. This involves gaining a deep understanding of the clients' needs and the insurance market landscape to ensure account retention, drive healthy revenue, and foster growth. Additionally, the role entails translating agreements and regulations into systems and processes, as well as monitoring insurance dispensing behavior and trends. The key objectives are to lower rejection rates, improve compliance, and ensure excellence and governance in insurance dispensing.
 

Accountabilities:

Contracting & Benefit File Excellence:
•    Ongoing maintenance of all payers contract to comply with regulators guideline, market practice & pharmacy operation 
•    Mange and update benefits file for all contracts according to regulator policies, payer requirements and policy table of benefits (TOB) in collaboration with medical training team to ensure right medical judgment 
•    Manage & update payer benefits file update in IMF and POS. 
•    Conduct regular benefits file review and analysis to improve the compliance 
•    Update the Monthly Benefit File.
 

Payer Operation Excellence:
•    Develop and ensure the deployment of all operation guideline as per the regulator policies and payer contract terms
•    Ongoing guideline review and update according to any changes
•    Conduct regular compliance review meetings with cross function to share compliance analysis and reports in order to develop the correction action plan in collaboration with IT, OPEX and claim teams
•    Develop and establish operation guidelines.
•    Prepare dispensing guidelines to ensure compliance with insurance requirements.
 

Payer Claim Excellence:
•    Measure and ensure the deployment of all claim requirement as per the regulator policies and payer contract terms
•    Ongoing claim requirements review and update according to any changes
•    Provide support for the control of claims rejection.
•    Control the dispensing of uncovered items.
•    Conduct analysis of claim rejections and identify areas for improvement.
 

Business management support 
•    Ensure accuracy and completeness of insurance data in the system.
•    Classify SFDA (Saudi Food and Drug Authority) and Patency discounts.
•    Set up ISP (Insurance Service Provider) rules.
•    Manage and oversee day-to-day operations related to insurance accounts.
•    Conduct training sessions for pharmacists to enhance their understanding of insurance processes.
•    Address inquiries and provide assistance to pharmacists regarding insurance-related matters.
•    Ensure proper archiving of insurance-related documents and records.
•    Prepare and document Service Level Agreements (SLAs) and Standard Operating Procedures (SOPs).

Functions:
•    Conduct dispensing guidelines training.
•    Ensure data accuracy and completion in claims processing.
•    Update the Benefit File and IDF.
•    Manage ISP rules and item identification.
•    Handle CCHI complaints.
•    Support NPHIES enrollment.
•    Control item dispensing through INS link.
•    Review SFDA codes for updates.
•    Generate patency classification reports.
•    Prepare rejection replies.
•    Conduct monthly claim and performance reviews.

Work Environment:

•    Indoors : 90%
•    Outdoors : 10% 
•    Working Days : 5 Working Days
•    Days off : 2 Days Off
•    Working Hours : 8:00 AM - 5:00 PM (1 hour break)
 

Job Requirements:

Education: Bachelor Degree, medical studies is preferred
Experience: 1 to 3 Years of Experience in providing medical services to insurance companies or corporate  
Computer Skills:  Analytical skills - MS Office Suite  - Awareness of Insurance System
Languages:   English - Arabic