Manager - Claims & Pre-Authorization

This role is responsible for leading and overseeing Pre-Authorization (PA) MENA and COE Claims Operations, ensuring timely, compliant, and high-quality service delivery across pre-authorization and claims functions.

The role is accountable for SLA performance, operational governance, regulatory and SOP compliance, quality management, escalation resolution, audit readiness, stakeholder engagement, people development, and continuous improvement to support member, provider, client, and business expectations.

· Oversee daily PA MENA and Claims Operations to ensure timely work allocation, queue management, backlog control, and delivery against agreed service standards.

Key measurable expectations include (subject to change):

o Urgent GOP requests: ≤ 1 hour

o Elective GOP requests: ≤ 24 hours

· Monitor provider call handling performance:

o ASA target: 20 seconds

o ABN target: 4%

o AHT target: 360 seconds

· Ensure claims processing targets are achieved:

o Member claims: 95% within 5 working days

o Provider claims: 95% within 20 working days

· Monitor daily inventory, aging cases, pending queues, high-risk cases, and backlog trends, with escalation of material SLA risks within the same business day.

· Ensure adherence to data protection, authority matrix, payer rules, regulatory requirements, SOPs, and internal governance controls, with zero tolerance for material compliance breaches.

· Maintain transaction quality through daily and monthly error reviews, root cause analysis, coaching, and corrective action plans, targeting agreed quality scores and reduction in repeat errors.

· Provide technical guidance on complex claims, pre-authorization decisions, policy interpretation, coding accuracy, clinical appropriateness, and payer-specific requirements.

· Compile and present monthly KPI reviews covering SLA performance, quality, productivity, escalations, operational risks, audit actions, staffing, and process improvement progress.

· Lead or participate in cross-functional workshops addressing clinical queries, customer feedback, audit findings, process gaps, and corrective actions.

· Monitor and control financial leakage and ex-gratia payments arising from operational errors, with action plans to reduce avoidable cost impact.

· Ensure SOPs, desktop procedures, trackers, authority controls, and governance documents are reviewed at least annually, updated for material process changes, and submitted for approval as required.

· Manage workflow prioritization, resource allocation, contingency planning, and business continuity arrangements during volume spikes, system issues, planned outages, or staffing constraints.

· Maintain operational trackers, team planners, attendance records, leave coverage plans, overtime logs, risk logs, and action trackers to support transparent governance and capacity planning.

· Track audit findings, quality issues, compliance gaps, and corrective actions through closure, targeting agreed closure timelines and sustainable prevention of repeat findings.

· Conduct structured daily huddles, regular one-to-one check-ins, and monthly performance reviews to align teams on SLA priorities, quality expectations, escalations, and operational risks.

· Set clear individual and team goals linked to SLA performance, quality scores, productivity, compliance adherence, attendance discipline, and customer/provider service outcomes.

· Identify capability gaps through quality trends, audit feedback, escalation patterns, and productivity data, and implement targeted coaching, refresher training, or buddy support plans.

· Maintain succession readiness and cross-skilling plans to ensure adequate coverage for critical activities, including urgent GOPs, high-value claims, escalations, and regulatory-sensitive cases.

· Promote a culture of accountability, continuous improvement, collaboration, and timely escalation, while supporting employee engagement and constructive feedback.

· Resolve complex, technical, high-value, clinical, policy, or contentious cases using medical, contractual, and operational expertise.

· Manage escalations through timely triage, ownership, stakeholder communication, root cause assessment, and closure within agreed turnaround expectations.

· Provide on-call or urgent operational support, including off-hours support where required for business-critical, member-impacting, or provider-impacting matters.

· Collaborate with Claims, PA, Clinical, Compliance, Client Management, Network, Finance, IT, Quality, TPAs, providers, and other stakeholders to ensure seamless process execution.

· Provide accurate ad hoc reports, trend analysis, claims or PA insights, and action plans to support Client Management, leadership reviews, and stakeholder updates.

· Represent PA MENA and COE Claims Operations in governance forums, leadership meetings, audit discussions, and service improvement reviews.

· Support onboarding, refresher training, policy updates, system training, and external or internal knowledge-sharing sessions as required.

· Translate performance trends, audit learnings, and stakeholder feedback into focused training priorities and measurable improvement actions.

· Maintain team knowledge readiness by ensuring updates on SOP changes, payer rules, coding guidance, regulatory expectations, and system/process changes are cascaded timely.

· Identify, prioritize, and implement process improvement initiatives that enhance SLA performance, quality, compliance, customer experience, automation, and operational efficiency.

· Participate in Health Cloud updates, claims platform enhancement discussions, workflow improvement forums, and user acceptance activities where required.

· Contribute to cross-functional projects aimed at improving medical operations efficiency, system integration, governance controls, reporting capability, and service resilience.

· Minimum 7–8 years of TPA, payer, insurer, or medical operations experience, with strong exposure to pre-authorization, claims processing, provider operations, and healthcare service delivery; clinical qualification such as MBBS or Dentistry is preferred.

· Strong knowledge of policy interpretation, medical coding, clinical appropriateness, payer requirements, authority matrix application, and regulatory expectations.

· Proven experience managing high-volume, SLA-driven operations with accountability for quality, productivity, compliance, escalations, and operational risk.

· Strong analytical, reporting, dashboard review, root cause analysis, and data-led decision-making capability.

· Excellent stakeholder management and communication skills

· Proven ability to lead teams, manage performance, coach for improvement, handle escalations, and operate effectively in high-pressure environments.

· Proficiency in operational systems (e.g., Health Cloud, claims platforms)

Pay: From AED20,000.00 per month