Senior Officer - Reimbursement & TPA Claims

Transguard Workforce Solutions

Senior Officer - Reimbursement & TPA Claims

Abu Dhabi

Job Summary

Job Responsibilities

• Review, validate, and process medical reimbursement claims in accordance with policy terms, medical necessity, and regulatory guidelines (DHA/DOH).
• Scrutinize claims thoroughly, ensuring completeness of documentation including invoices, prescriptions, medical reports, and pre-authorizations.
• Identify valid vs. non-compliant claims and process approvals in line with the authority matrix.
• Handle walk-in customers and respond to client/broker queries via phone and email with clarity and professionalism.
• Monitor and manage TPA claims, including submissions, high-cost claims, daily settlements, and dashboard reporting.
• Ensure claims exceeding TPA limits are escalated and approved appropriately.
• Detect potential fraudulent or abusive claim patterns and escalate to management.
• Reject ineligible claims with accurate denial codes and proper justification.
• Collaborate with audit/medical evaluation teams on complex cases.
• Maintain consistent dual-check processes to ensure accuracy and quality.
• Contribute to process improvements, cost containment initiatives, and regular updates of medical coding knowledge.

Job Requirements

• Bachelor’s degree in Medicine, Dentistry, Pharmacy, Nursing, or Paramedical Sciences
• 3-5 years of relevant experience in medical claims, insurance, or TPA operations
• Professional certifications such as CPC / AHIMA (preferred)
• Strong understanding of medical adjudication, insurance policies, and healthcare regulations
• Strong analytical and attention-to-detail skills
• Knowledge of reimbursement processes and TPA frameworks
• Excellent communication and customer service skills
• Ability to handle high volumes with accuracy and efficiency
• Sound judgment in fraud detection and claims validation
• Full professional proficiency in English