Senior Rejection Control Specialist

PHCC has a vision to be the leader in transforming the health and wellbeing of people’s lives in Qatar. PHCC’s mission is to deliver comprehensive, integrated and coordinated person-centered health care services in the community through focusing on disease prevention, healthy lifestyles and wellness. In partnership with our stakeholders, we will improve the health and wellbeing of our population.

The incumbent is responsible for leading and managing the review, analysis, and resolution of insurance claim rejections within PHCC. This role ensures the accuracy, compliance, and efficiency of the claims process, proactively identifies trends and root causes of rejections, and implements strategies to minimize future denials.

Key Accountabilities & Duties:

• Oversee the review and analysis of rejected insurance claims, ensuring timely resolution and resubmission.
• Investigate reasons for claim rejections, coordinate with clinical, coding, and billing teams to correct errors, and facilitate appeals as necessary.
• Ensure compliance with regulatory guidelines, payer requirements, and PHCC policies in all claim handling activities.
• Liaise with insurance companies, and third-party administrators to resolve complex claim issues.
• Analyze rejection and denial data to identify trends, root causes, and opportunities for process improvement.
• Prepare regular reports for management, highlighting key metrics, issues, and recommendations.
• Develop and implement operational workflows and controls to minimize claim rejections and ensure compliance with regulatory standards.
• Participate in audits and quality assurance activities related to claims management.
• Stay updated on changes in insurance regulations, coding standards, and payer policies.
• Train and mentor the respective team and other stakeholders on best practices for claims submission, rejection management, and resubmissions.
• Collaborate with internal stakeholder departments to ensure seamless claims processing and resolution.
• Demonstrate proactive approach to patient safety by thinking what might go wrong in all your undertakings and take necessary measures to prevent them from happening.
• Identify and report potential or actual patient safety concerns, errors and/or near misses in timely manner.
• Partner with line manager to understand risks in your area of work, develop a plan on how to mitigate those risks, and develop shared accountability for implementing and evaluating the plan.
• Ensure high standards of confidentiality to safeguard any sensitive information.
• The incumbent will undertake any such related duties or responsibilities as directed.

Education Requirements: Bachelor’s degree in business administration, Finance, Health Information Management, or a related field.

Certification, license or training Requirements: Certification in medical billing/coding (e.g., CPC, CPB) or insurance claims management preferred.

Experience & Knowledge: Minimum 5 years of experience in health insurance claims management

Proven expertise in handling claims rejections, appeals, and payer communications in a healthcare  knowledge of insurance workflows, billing, coding, reimbursement policies, and regulatory compliance.