Senior Officer Reimbursement & TPA

About the role

The Senior Officer – Reimbursement & TPA will work from the Abu Dhabi office, handling medical claim intake, validation and settlement in line with insurance policies and company standards. The role also involves direct interaction with walk‑in customers, ensuring clear explanations and efficient service.

Key responsibilities

• Receive and review medical claims delegated by the supervisor, performing medical adjudication to verify diagnosis, investigations and prescriptions.
• Process paper claims, ensuring all required documents (original claim forms, invoices, prescriptions, pre‑authorisations, receipts, medical reports, etc.) are complete and accurate.
• Identify valid and invalid claims, dual‑check processed claims and obtain approval according to the authority matrix.
• Monitor TPA claim submissions, manage settlements and reject ineligible claims with appropriate denial codes.
• Detect and analyse provider abuse trends and escalate findings to the supervisor.
• Prepare and deliver management reports on unit performance and compliance with policies and procedures.

Required profile

• University degree (field not specified).
• Minimum 36 months of experience in medical claims processing or related healthcare reimbursement functions.
• Strong attention to detail and ability to work under defined policies and procedures.

Required skills

• Medical Adjudication
• Medical Claims Processing