Job Description

We are seeking a qualified and experienced Executive Officer – Medical Claims to join our team. The role involves adjudicating and auditing inpatient (IP) and outpatient (OP) medical claims under the Health Takaful portfolio (Individual and Group), ensuring compliance with internal policies and industry standards. Responsibilities include efficient claims management, cost containment through audits and case management, timely resolution of customer queries, and close collaboration with Third Party Administrators (TPAs) to deliver excellent service while meeting key performance indicators (KPIs).

Job Responsibilities:

Claims Adjudication and Audit

• Review and adjudicate medical claims (IP/OP) within agreed turnaround times and in accordance with policy terms.
• Ensure adherence to claims procedures, medical coding standards, and compliance with international guidelines.
• Conduct periodic audits of TPA-processed claims.
• Identify and flag suspicious or fraudulent claims and providers for further investigation.

Cost Containment and Case Management

• Analyse high-cost claims and collaborate with case management units to achieve cost savings and maintain financial efficiency.
• Achieve targeted savings through audits and medical necessity evaluations.

Stakeholder Coordination

• Liaise with TPAs, network providers, and medical professionals to ensure accurate claims evaluation and reconciliation.
• Respond to customer and broker queries related to claims, pre-approvals, denials, and documentation within defined timeframes.
• Collaborate with internal teams and other departments to facilitate seamless claims handling and payment processing.

Customer Service and Communication

• Ensure all clients and stakeholders receive professional, timely, and clear responses to inquiries.
• Provide justifications and explanations for claim outcomes, maintaining transparency and satisfaction.
• Educate brokers and clients on claims submission procedures.

Job Requirements:

• Bachelor’s degree in medicine and surgery (M.B.B.S.) or equivalent medical qualification.
• CPC or Medical Transcriptionist certification is preferred.
• Minimum of 3 years of hands-on experience in health claims management within the UAE, including direct work with Third Party Administrators and multicultural teams.
• Prior experience in the insurance industry or similar roles.
• Bilingual fluency in English and Arabic.
• Proficiency in Microsoft Office applications, particularly Excel.
• Excellent verbal and written communication skills.