وظيفة مدير أول - المطالبات الطبية شاغرة لدى التعاونية للتأمين بالرياض

Job Purpose:

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.