Senior Officer Reimbursement & TPA

Required Skills

The job holder is responsible to receive medical claims as delegated by Supervisor; review, validate and ensure prompt action in compliance with insurance policies, set company standards, procedures and guidelines. Handle Walk-in customers in the most efficient way, ensuring most satisfactory clarifications are provided. Handle dedicated claims with authority as per limits with utmost care and accountability. Detect and analyze provider trends of abuse and escalate to immediate supervisor. Requires a University Degree in Medicine/Dentistry/Pharmacy/Nursing/Paramedics and 3 to 5 years of relevant experience in reviewing, validating, and processing medical reimbursement claims accurately and within policy guidelines.

Transguard Workforce Solutions is the UAE's leading provider of unique and innovative HR solutions. With a decade of experience in the region and a team that possesses extensive knowledge of the market, we provide a fully integrated HR solution.We are currently recruiting for a Senior Officer – Reimbursement & TPA for our client to be based out of their Abu Dhabi Office. Purpose-The job holder is responsible to receive medical claims as delegated by Supervisor; review, validate and ensure prompt action in compliance with insurance policies, set company standards, procedures and guidelines. Handle Walk-in customers in the most efficient way, ensuring most satisfactory clarifications are provided. Handle dedicated claims with authority as per limits with utmost care and accountability. Detect and analyze provider trends of abuse and escalate to immediate supervisor.Responsibility-Policies, Processes and procedures: Follow all relevant departmental policies, processes, standard operating procedures and instructions so that work is carried out in a controlled and consistent manner.Medical Claims Processing Activities: Receive claims from Supervisor; performs review based on Medical Adjudication by scrutinizing the claims thoroughly to see whether the diagnosis, investigations and prescription are justified taking into consideration the Diagnosis or Medical Condition.Paper claims: Original Claim form duly filled by the Medical Practitioner carrying member's signature, medical necessity, Original Invoices/ Original prescription of the dispensed medications(except for controlled medications), prices of the services, Pre-authorization, if any, Receipts of deductibles & Co-payment in original, Statement of Accounts, medical reports, investigation reports, ln-patient invoices with detailed breakdown of cost along with operative notes if any and discharge summary.Reimbursement: Identifying valid and invalid claims during the course of scrutiny as above. The processed claims are dual checked. After the same is completed, approval as per Authority matrix is obtained before finalization.TPA: Monitor TPA claims submissions for settlement.Rejection of Claims: Claims not eligible for settlement to be rejected with appropriate denial codesReports: Provide Management with appropriate reports regarding the unit and compliance with operational policy and procedures.Skills-University Degree in Medicine/Dentistry/Pharmacy/Nursing/Paramedics.3 to 5 years of relevant experience in reviewing, validating, and processing medical reimbursement claims accurately and within policy guidelines.