Quality Lead

About the Role

The Quality Lead will oversee the Inpatient Precertification cases, ensuring departmental objectives, timelines, and compliance standards are met. This role operates within a 24/7 functional team, requiring flexible shift work as scheduled by the Team Leader.

Responsibilities

• Adjudicate Inpatient precertification cases, making authorization decisions within the defined turnaround times and adhering to policy terms and conditions with high-quality standards.
• Conduct thorough reviews of patient files, including multidisciplinary notes, TPR charts, physician orders, lab and radiology reports, drug charts, consultation notes, and progress notes.
• Identify and request any missing medical documentation essential for decision-making.
• Review DRG Severity of Illness (SOI) and CPT/ICD code revisions, particularly when providers attempt to up-code, consulting with treating physicians and medical coders as needed.
• Perform utilization reviews for DRG and FFS cases, examining final bills, consumable markups, non-covered items/services, and overutilization of services.
• Review claims in accordance with CPT and ICD coding guidelines, ensuring compliance with insurance regulators such as DHA, DOH/HAAD, and MOH.
• Implement cost containment protocols for medical management cases.
• Refer cases for second opinions when necessary to confirm optimal management strategies and facilitate cost containment by utilizing lower Negotiating Factor (NF) facilities within the member's network or considering treatment in the home country.
• Adapt to and effectively utilize an environment shaped by artificial intelligence (AI), machine learning, data analytics, and cloud-based tools, applying insights responsibly according to data governance, security, and ethical standards.

Requirements

• Bachelor's degree in Pharmacy, Dentistry, Medicine, Nursing, Physiotherapy, or Paramedics.
• 1-2 years of practical medical experience; experience with a reputable insurance provider, broker, or TPA is advantageous, though entry-level candidates are also considered.
• Physically fit to perform job duties.
• Certified Medical Coder qualification is preferred.
• Legal authorization to work in the country of operations.
• Proficiency in MS Office Suite (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.

Perks

Allianz Partners is a global leader in B2B2C insurance and assistance, offering comprehensive solutions in international health and life, travel insurance, automotive, and assistance. We are customer-focused, with innovative experts redefining insurance services through future-ready, high-tech, and high-touch products. Our offerings are integrated into partner businesses or sold directly to consumers via brands like Allianz Assistance, Allianz Automotive, Allianz Travel, and Allianz Care. We are at the forefront of AI transformation, leveraging Business Intelligence and Data Analytics for strategic decision-making and enhanced customer experiences. Our commitment to Ethical AI ensures responsible deployment, data integrity, and trust. We utilize Conversational AI for improved communication and Emerging Technologies, including Generative AI, to drive industry leadership. Robust Information Security Management protects sensitive data, ensuring compliance and security. Join us to shape the future of AI in insurance.

Eligibility

Candidates with a Bachelor's degree in Pharmacy, Dentistry, Medicine, Nursing, Physiotherapy, or Paramedics are eligible. A minimum of 1-2 years of practical medical experience is preferred, though entry-level candidates with the required educational background will be considered. Experience with insurance providers, brokers, or TPAs is a plus. Applicants must be legally permitted to work in the UAE and be physically fit for the role. A Certified Medical Coder qualification is desirable.

Education Required

Bachelor's degree in Pharmacy, Dentistry, Medicine, Nursing, Physiotherapy, or Paramedics.

Skills

• Medical Case Management
• Insurance Claims Adjudication
• Utilization Review
• Medical Coding
• Policy Interpretation
• Data Analysis
• AI Readiness
• MS Office Proficiency
• Communication Skills
• Problem-Solving