Employee Health Insurance Senior Specialist

Job Title Employee Health Insurance Senior Specialist
Division Human Resources
Section Total Rewards
Report To Total Rewards Senior Manager
Location Madani
Main Job Purpose:
The primary objective of this role is to process complex health insurance claims for a wide network of
healthcare providers. This role involves ensuring accurate documentation review, medical coordination,
financial reconciliation, and system entry. Additionally, ensures compliance with health insurance policies,
supports financial approval processes, and serves as a key operational point of contact for contracting
parties, physicians, employees, and finance teams, contributing to data integrity, financial accuracy, and
service reliability.
Duties & Responsibilities:
1. Manage and process health insurance claims for assigned contracting parties across multiple regions
by receiving submissions through various communication channels and ensuring timely handling.
2. Review and validate claim documentation to ensure completeness, accuracy, and compliance with
approved health insurance policies and operational procedures.
3. Communicate proactively with contracting parties to resolve missing or incomplete documentation
using the most effective and accessible communication channels.
4. Coordinate claim reviews with healthcare physicians by submitting claims for medical validation,
addressing clarification points, and following up until final medical decisions are issued.
5. Enter and maintain claims data accurately within the health insurance system by inputting each form
individually, ensuring correctness of file numbers, data integrity, and consistency between system
entries and supporting documents.
6. Liaise with healthcare physicians to clarify medical decisions, pricing points, or procedural
discrepancies arising during the review process.
7. Communicate with employees, when required, to verify medical procedures provided by contracting
parties and ensure correct entitlement application.
8. Prepare and analyze detailed claim reports that clearly outline the requested amounts, approved
amounts, and final entries, including comprehensive explanations following medical review and
financial reconciliation.
9. Consolidate reviewed claims and supporting documentation using approved file-linking tools,
ensuring proper compilation into a single, accurate file for financial approval processing.
10. Coordinate with financial approvals officers by submitting consolidated claim files, reviewing details
jointly when required, and supporting resolution of any identified discrepancies.
11. Verify claim values with contracting parties upon request, providing professional explanations in line
with medical reviews, contractual terms, and policy guidelines.
12. Respond to inquiries from contracting parties regarding health insurance policies, procedures, and
regulations, ensuring accurate, consistent, and timely guidance.
13. Maintain comprehensive and organized claim records to support audits, financial reconciliation, and
future reference.
14. Follow up on critical medical and operational issues impacting employees by coordinating with HR,
medical providers, and internal teams to ensure timely resolution and continuity of care.
15. Support network expansion initiatives within the assigned area by coordinating onboarding activities
for new healthcare providers, facilitating operational readiness, and supporting contract activation
processes.
16. Promote and maintain a positive medical care image by ensuring high service standards, professional
communication, and compliance with HR and health insurance service expectations.
Behavioral Competencies:
1. Communication: Conveys information clearly and professionally to employees, healthcare
providers, and internal stakeholders, ensuring mutual understanding and timely resolution of
inquiries.
2. Collaboration: Works effectively with HR, finance, medical providers, and external partners to
achieve shared objectives and ensure smooth execution of health insurance processes.
3. Problem Solving: Identifies and analyzes operational issues related to claims, billing, and enrollment,
applying standard procedures and sound judgment to resolve issues effectively.
4. Attention to Detail: Maintains high levels of accuracy in claims processing, system updates, and
documentation to minimize errors and ensure compliance with health insurance policies.
5. Customer Focus: Demonstrates a service-oriented mindset by responding promptly to employee
and provider needs, ensuring continuity of medical coverage and a positive employee experience.
6. Getting Things Done: Focuses on achieving accurate, timely, and compliant outcomes by prioritizing
tasks, meeting service standards, and ensuring health insurance activities are completed efficiently
and within agreed timelines.
Technical Competencies:
1. Health Insurance Claims Processing: Advanced knowledge of end-to-end claims workflows,
documentation requirements, and approval stages.
2. Health Insurance Systems: Proficient in entering, tracking, and reconciling claims within health
insurance platforms.
3. Medical Review Coordination: Ability to work closely with physicians to address clinical review
outcomes and clarifications.
4. Financial Reconciliation: Skilled in comparing requested, approved, and final amounts, and
explaining variances clearly.
5. Policy & Regulatory Compliance: Applies health insurance policies, contractual terms, and internal
procedures accurately across all transactions.
6. Claims Audit & Documentation Control: Ability to maintain complete, accurate, and well-structured
claim files by ensuring proper documentation, traceability, and readiness for internal reviews,
financial audits, and regulatory inspections.
Qualifications:
Education
A bachelor’s degree in Business Administration, Accounting, Healthcare Management, or
a related field.
Experience
• 1-3 years of experience in health insurance operations, medical administration, or
financial processing.
• Experience working with healthcare providers, claims processing, and financial
systems is preferred.
Certificates Health Insurance or medical administration certifications are an advantage.
Language Intermediate in the English language (Written & Spoken).