Executive - Medical Claims

Job Title: Executive - Medical Claims
Department: Medical
Job Purpose
To provide operational and administrative support for medical claims processing activities by ensuring accurate documentation handling, claim registration, verification, coordination with TPAs. The role ensures efficient claims workflow, proper maintenance of claims records and communication channels, and accurate claims data that supports monitoring of the medical loss ratio
Duties & Responsibilities
Ensure profitable management of the medical insurance portfolio
Receive, register, and record medical claims and supporting documentation
Verify completeness of claim submissions in accordance with required documentation standards
Coordinate with policyholders, TPAs, and relevant stakeholders to obtain missing information
Maintain organized claims records and documentation in accordance with company procedures
Support verification of policy coverage, eligibility, and claim validity
Assist in processing and tracking claims through various stages of approval and settlement
Coordinate with TPAs regarding claim submissions, updates, and operational requirements
Support preparation of reimbursement related documentation and processing activities
Maintain claims databases and update system records accurately
Respond to routine queries from policyholders regarding claim status and documentation
Support investigation activities by collecting and organizing required claim information
Escalate complex or disputed claims cases to relevant teams for review
Assist in coordination of claim-related communication between internal and external stakeholders
Support reporting requirements related to claims operations and processing activities
Contribute to maintaining operational accuracy, efficiency, and service quality in claims administration
Perform medical activities for Bank Muscat project, ensuring maximum conversion rates against agreed targets
Coordinate the Bank Muscat project end to end, including outbound customer calls, follow-up, and closure of medical policies
Process medical claims cases end to end, from registration through assessment, approval, and final settlement
Provide timely support to customers and clients, resolving queries and complaints within the agreed TAT
Perform finance reconciliation for medical claims, ensuring settlements, recoveries, and TPA balances are accurately matched and reported
Process medical policy cancellations, including premium refund calculations and updating of system and policy records
Evaluate motor claims cases involving medical injury and coordinate with the motor team on assessment and settlement of medical costs
Undertake any other tasks delegated by the Head of Department, in line with the role and business requirements
Qualifications & Experience
Bachelor's Degree in Medical, Insurance, Finance, or related field
Professional insurance qualification (CERT CII or equivalent) is an advantage
Minimum 0–2 years of experience in insurance administration or medical claims support
Basic understanding of medical insurance claims processes and documentation requirements
Experience working with insurance systems and administrative workflows
Good knowledge of customer service and data handling in insurance operations
Competencies
Medical claims documentation and registration knowledge
Attention to detail and accuracy
Coordination with TPAs and stakeholders
Communication and customer service orientation
Time management and organizational skills
Teamwork and collaboration
Data handling and record-keeping accuracy
Compliance and process adherence