Job Description

Medical Officer – Outpatient Precertification is responsible for managing the Outpatient Precertification claims while ensuring that departmental goals, timeline of activities, and compliance measures are met.

What You Do

• Precertification team is functional on 24/7 basis. Therefore, the Medical Officer will work on a flexible shift basis as per the schedule provided by the Team Leader.
• Adjudicates – outpatient medical claims by evaluating each case from both the technical and clinical perspectives, ensuring all decisions comply with policy terms and conditions and are delivered within the stipulated turnaround time and quality standards.
• Performs a comprehensive review of outpatient documentation, including consultation notes, diagnostic reports, laboratory results, radiology findings, prescriptions, treatment plans, and follow‑up notes to validate medical necessity and appropriateness of care.
• Assesses the necessity and justification of proposed treatment plans, ensuring alignment with evidence‑based guidelines and outpatient benefit structures
• Requests additional medical documentation or identifies missing information essential for accurate decision‑making, coordinating with providers when clarification is required
• Conducts utilization review for outpatient services, including but not limited to evaluation of billed items, non‑covered services, overutilization patterns, and appropriateness of investigations or procedures.
• Performing review of claims as per CPT and ICD coding guidelines in line with insurance regulators (DHA,DOH/HAAD,MOH).
• Adheres to cost‑containment protocols by ensuring outpatient services are medically justified, appropriately billed, and aligned with network rules and negotiated tariffs
• Maintains daily productivity and service level targets, ensuring timely adjudication and consistent workflow management
• AI READINESS Work effectively in an environment shaped by artificial intelligence (AI), machine learning, data, analytics and cloud-based tools, using insights responsibly with our standards of data governance, security and ethical use.
  

What You Bring

• Bachelor’s of Dentistry / Nursing / Paramedics
• 1-3 years of Medical Practical Experience (reputable insurance provider, broker or a TPA experience a plus)
• Physically fit to carry out duties.
• Certified Medical Coder [Preferable]
• Legally permitted to work in the country of operations.
• Physically fit to carry out duties.
• Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.
• Strong English communication skills, both verbal and written, with excellent interpersonal and stakeholder management abilities
• Abu Dhabi and Al-Ain Market knowledge