Medical Audit Doctor

Job Summary:

The Medical Audit Doctor is responsible for reviewing and auditing medical insurance claims, ensuring compliance with regulatory standards, and verifying the necessity of treatments and medical procedures. This role involves assessing medical records, identifying discrepancies, and providing recommendations to optimize claim processing and cost containment.

Key Responsibilities:

1. Evaluate medical insurance claims to ensure alignment with insurance policies and guidelines.
2. Assess the necessity and appropriateness of treatments, medications, and diagnostic procedures.
3. Identify fraudulent claims, excessive billing, and inappropriate medical coding.
4. Ensure compliance with Saudi Arabian IA and Council of Health Insurance (CHI) regulations.
5. Review and approve/reject claims based on medical necessity and policy terms.
6. Identify and report fraudulent claims, overutilization of services, and unethical practices.
7. Implement cost containment strategies to optimize medical expense management.
8. Collaborate with claims, underwriting, and risk management teams to enhance fraud prevention measures.
9. Work closely with hospitals, clinics, and healthcare providers to validate claims and ensure proper documentation.
10. Communicate audit findings with internal departments, including claims processing, underwriting, and compliance teams.
11. Provide technical guidance to claims processors and insurance officers on medical-related queries.
12. Ensure adherence to Saudi healthcare regulations, insurance laws, and CHI/IA standards.
13. Participate in policy development and process improvements to enhance audit efficiency.
14. Conduct periodic audits of medical claims and prepare reports for senior management.
15. Maintain detailed records of audit findings and recommendations.
16. Develop reports on claim trends, fraud patterns, and cost-saving opportunities.
17. Present findings to management with recommendations for policy enhancements.
18. Drive innovation in threat intelligence tools and methodologies.

Requirements:

• Bachelor’s degree in medicine (MBBS/MD).
• Certification in Medical Audit, Health Insurance, or Medical Coding (e.g., CPC, CPHQ, or equivalent) is preferred.
• Minimum 1-3 years of experience in medical claims auditing, health insurance, or hospital administration.
• Strong understanding of medical coding systems (ICD-10, CPT, DRG) and insurance regulations.
• Experience in fraud detection, cost control strategies, and medical policy compliance.
• Familiarity with IA, CHI, and other regulatory standards governing health insurance in Saudi Arabia.
• Strong analytical and problem-solving skills.
• Excellent communication and negotiation skills.
• Attention to detail and ability to identify inconsistencies in medical claims.
• Proficiency in MS Office (Excel, Word, PowerPoint).
• Ability to work under pressure and meet deadlines.