RCM - Medical Claims Specialist

Join My Clinic, the leading multispecialty outpatient care provider in Saudi Arabia, where our mission to help people live longer, healthier, and happier lives drives everything we do. Since 2017, we've been at the forefront of healthcare, combining innovation with a deep commitment to care, collaboration, ambition, and responsibility. As we continue to grow and reach new heights, we're looking for passionate individuals who share our vision and values. Job Summary: Support the Medical Operations function by performing clinical review and validation of insurance claims before submission, ensuring medical necessity, documentation completeness, coding/service consistency, and compliance with payer and RCM requirements. The role supports the growing monthly claims volume and new branch expansion by identifying claim risks early and coordinating corrections to improve clean-claim quality and reduce rejections and write-offs. Primary Responsibilities: • Perform detailed clinical review and validation of medical claims prior to submission to ensure accuracy, completeness, and claim readiness. • Validate medical necessity, diagnosis, investigations, procedures, medications, and other billed services against the patient medical record and documented plan of care. • Review claim documentation for completeness and consistency, including physician notes, reports, orders, results, supporting documents, and required attachments. • Identify clinical, coding, documentation, utilization, duplicate-service, unbundling, approval, eligibility, and payer-rule risks that may lead to rejection, deduction, or write-off. • Ensure consistency between services rendered, approvals obtained, quantities/sessions, diagnosis and procedure coding, and billed claim lines before final submission. • Coordinate with physicians, Medical Operations, Pre-Authorization, Claims/Billing, Operations, and other relevant teams to clarify discrepancies and complete required corrections within submission timelines. • Review rejected or deducted claims from a clinical perspective, identify root causes, support rework/resubmission where applicable, and recommend corrective and preventive actions to reduce recurrence. • Monitor recurring claim issues and rejection trends, provide feedback to the Medical Operations Lead, and support targeted education or process improvements for clinical and operational teams. • Support claim quality audits, payer queries, reconciliation activities, and documentation requests, including preparation of clinical justification and supporting evidence when required. • Support new branches, new services, payer activations, and increasing claim volumes by applying standardized medical claim validation processes and escalating material risks promptly. • Perform other professional duties as assigned by the Line Manager. Education / Professional Qualifications: • Education Degree (Required): Bachelor’s degree in medicine (MBBS/MD), Pharm D, Biology, microbiology, Chemistry, or equivalent medical\clinical qualification. • Years of Experience (Required): Minimum 2 years of experience in healthcare, medical insurance, claims review, utilization review, or Revenue Cycle Management; experience in a high-volume outpatient setting is preferred. • License: (optional) Valid Saudi Commission for Health Specialties (SCFHS) classification/registration, where applicable to the professional qualification. • Professional Certification (Optional): Certification or formal training in medical coding, health insurance, claims management, or Revenue Cycle Management is preferred. Show more Show less

Minimum 2 years of experience in healthcare, medical insurance, claims review, utilization review, or Revenue Cycle Management; experience in a high-volume outpatient setting is preferred. Education: Bachelor’s degree in medicine (MBBS/MD), Pharm D, Biology, microbiology, Chemistry, or equivalent medical/clinical qualification. License: Optional SCFHS classification/registration where applicable. Professional Certification (Optional): Certification or formal training in medical coding, health insurance, claims management, or Revenue Cycle Management is preferred.

Perform detailed clinical review and validation of medical claims prior to submission to ensure accuracy, completeness, and claim readiness. Validate medical necessity, diagnosis, investigations, procedures, medications, and other billed services against the patient medical record and documented plan of care. Review claim documentation for completeness and consistency, including physician notes, reports, orders, results, supporting documents, and required attachments. Identify clinical, coding, documentation, utilization, duplicate-service, unbundling, approval, eligibility, and payer-rule risks that may lead to rejection, deduction, or write-off. Ensure consistency between services rendered, approvals obtained, quantities/sessions, diagnosis and procedure coding, and billed claim lines before final submission. Coordinate with physicians, Medical Operations, Pre-Authorization, Claims/Billing, Operations, and other relevant teams to clarify discrepancies and complete required corrections within submission timelines. Review rejected or deducted claims from a clinical perspective, identify root causes, support rework/resubmission where applicable, and recommend corrective and preventive actions to reduce recurrence. Monitor recurring claim issues and rejection trends, provide feedback to the Medical Operations Lead, and support targeted education or process improvements for clinical and operational teams. Support claim quality audits, payer queries, reconciliation activities, and documentation requests, including preparation of clinical justification and supporting evidence when required. Support new branches, new services, payer activations, and increasing claim volumes by applying standardized medical claim validation processes and escalating material risks promptly. Perform other professional duties as assigned by the Line Manager.