Pharmacy Claims Adjudication Executive

About the role

The Pharmacy Claims Adjudication Executive will join a leading client in the UAE to ensure accurate and timely processing of outpatient pharmacy claims. This role requires a qualified pharmacy professional with strong analytical abilities to evaluate claim eligibility, medical necessity, and policy compliance.

Key responsibilities

• Review and adjudicate outpatient pharmacy claims for medical necessity, eligibility, and policy coverage.
• Verify prescriptions, dosage, quantity, formulary status, limits, and applicable policy terms.
• Identify duplicate, inappropriate, excessive, or potentially fraudulent pharmacy claims.
• Apply policy terms, medical guidelines, formularies, and insurer rules.
• Review pre‑authorization requests for high‑cost and specialty medications.
• Coordinate with providers, pharmacists, insurers, and medical teams for clarification and additional information.
• Maintain accurate documentation and ensure objective, timely claim decisions.

Required profile

• B.Pharm or Pharm.D. from a recognized institution.
• UAE‑licensed or eligible pharmacist preferred.
• 3–5 years of experience in pharmacy, medical insurance claims, hospital pharmacy, or insurance adjudication.
• Experience in pharmacy claims adjudication and medical coding preferred.
• Knowledge of UAE health insurance, pharmacy claims, and medication regulations.

Required skills

• Pharmacy claims adjudication
• Medical coding
• Understanding of insurance policies, formularies, exclusions, co‑payments, limits, and prior authorization