Health Claims Specialist

To review, evaluate, and authorize medical claims and treatment requests in accordance with policy terms, medical necessity guidelines, UAE regulatory requirements, and internal service standards. Key Responsibilities • Review and evaluate pre-authorization requests submitted through TPAs for planned medical procedures, surgeries, diagnostic tests, treatments, and high-cost medications. • Assess medical records, physician reports, treatment plans, and supporting clinical documentation to determine medical necessity and appropriateness of care. • Approve, modify, defer, or decline authorization requests based on policy coverage, clinical guidelines, and regulatory requirements. • Provide clear clinical justification and documentation supporting authorization decisions. • Monitor TPA authorization practices and provide recommendations to ensure consistency and adherence to insurer guidelines. • Review and adjudicate reimbursement claims submitted by insured members to ensure compliance with policy benefits and coverage provisions. • Evaluate diagnosis, treatment plans, procedures, investigations, and prescribed medications for medical necessity and appropriateness. • Verify coding accuracy, policy coverage, exclusions, limits, deductibles, and co-payment requirements. • Assess supporting documentation including medical reports, invoices, prescriptions, referral letters, and discharge summaries. • Identify non-covered services, duplicate claims, excessive billing, upcoding, abuse, waste, and potential fraudulent activities. • Ensure fair, accurate, and timely settlement recommendations in line with established service level agreements. Pre-requisite • MBBS / MD or equivalent medical degree recognized by the relevant health authority. • 3–7 years of clinical practice and/or health insurance claims management experience. • Experience in preauthorization, utilization management, medical claims review, or managed care preferred. • Familiarity with health insurance regulations and healthcare reimbursement processes. • A physician with strong experience in the UAE health insurance claims process, possessing a comprehensive understanding of DOH, DHA, and MOHAP regulations. Show more Show less

MBBS / MD or equivalent medical degree recognized by the relevant health authority. 3–7 years of clinical practice and/or health insurance claims management experience. Experience in preauthorization, utilization management, medical claims review, or managed care preferred. Familiarity with health insurance regulations and healthcare reimbursement processes. A physician with strong experience in the UAE health insurance claims process, possessing a comprehensive understanding of DOH, DHA, and MOHAP regulations.

Review and evaluate pre-authorization requests submitted through TPAs for planned medical procedures, surgeries, diagnostic tests, treatments, and high-cost medications. Assess medical records, physician reports, treatment plans, and supporting clinical documentation to determine medical necessity and appropriateness of care. Approve, modify, defer, or decline authorization requests based on policy coverage, clinical guidelines, and regulatory requirements. Provide clear clinical justification and documentation supporting authorization decisions. Monitor TPA authorization practices and provide recommendations to ensure consistency and adherence to insurer guidelines. Review and adjudicate reimbursement claims submitted by insured members to ensure compliance with policy benefits and coverage provisions. Evaluate diagnosis, treatment plans, procedures, investigations, and prescribed medications for medical necessity and appropriateness. Verify coding accuracy, policy coverage, exclusions, limits, deductibles, and co-payment requirements. Assess supporting documentation including medical reports, invoices, prescriptions, referral letters, and discharge summaries. Identify non-covered services, duplicate claims, excessive billing, upcoding, abuse, waste, and potential fraudulent activities. Ensure fair, accurate, and timely settlement recommendations in line with established service level agreements.