Senior Officer - Reimbursement & TPA Claims

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 a Senior Officer - Reimbursement & TPA Claims for one of our client, based out of their office in Abu Dhabi, UAE.Job Summary:We are looking for a detail-oriented and proactive Senior Officer - Reimbursement & TPA Claims to handle end to end claims adjudication, ensuring accurate and timely processing while adhering to company policies and regulatory requirementsJob 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 Sciences3-5 years of relevant experience in medical claims, insurance, or TPA operationsProfessional certifications such as CPC / AHIMA (preferred)Strong understanding of medical adjudication, insurance policies, and healthcare regulationsStrong analytical and attention-to-detail skillsKnowledge of reimbursement processes and TPA frameworksExcellent communication and customer service skillsAbility to handle high volumes with accuracy and efficiencySound judgment in fraud detection and claims validationFull professional proficiency in English