Location: Cairo, Egypt
Role Purpose: The Claims Retrospctive Officer is responsible for the clinical assessment and adjudication of medical claims, ensuring compliance with medical necessity, policy coverage, and clinical guidelines. This role combines the expertise of a physician with the operational duties of a claims officer to deliver high-quality service and decision-making in a fast-paced environment.
Key Responsibilities / What you do:
Conduct clinical assessments of inpatient and outpatient medical claims to ensure accuracy and compliance with policy terms and clinical guidelines.
Validate diagnoses, procedures, and services against medical records and policy terms.
Identify discrepancies, overutilization, or non-compliance with guidelines.
Collaborate with claims teams to support adjudication decisions and ensure alignm...