Full job description

Company Description

GlobeMed Gulf Healthcare Solutions has been a leader in healthcare benefits management since 2013, operating in the UAE with a mission to enhance access to healthcare while managing costs. The company provides cutting-edge solutions, including network management, utilization review, and advanced business intelligence tools, supported by innovative and automated technology. As part of the reputable GlobeMed Group, which has over 33 years of experience and a network in 11 MENA region countries, GlobeMed Gulf offers exceptional, technology-driven healthcare solutions and services to its partners and clients.

Role Description

The Claims Officer is responsible for reviewing, auditing, and validating medical claims received from healthcare providers to ensure accuracy, compliance with contractual terms, and adherence to internal policies. The role involves identifying discrepancies, preparing settlement documentation, supporting risk carriers, and contributing to fraud detection efforts to secure financial accuracy and operational efficiency.

Duties & Responsibilities:

1. Receive, review, and audit medical claims submitted by contracted providers to ensure alignment with policy terms, medical necessity standards, and pricing agreements.

2. Conduct detailed claim audits and prepare the Examination of Invoice reports to highlight discrepancies, justify adjustments, and document outcomes.

3. Validate claims through verification of coding accuracy, eligibility, utilization rules, and benefit coverage.

4. Organize, classify, and close processed claims by provider, guarantor, and group for accurate reporting and settlement.

5. Prepare and issue bordereaux for reimbursements and general claims, ensuring timely submission to companies and stakeholders.

6. Monitor and follow up on pending, incomplete, or missing claims to maintain workflow timeliness.

7. Support the processing of complex, high-cost, inpatient, or exceptional claims as needed.

8. Liaise with risk carriers/insurers to provide clarification, feedback, and supporting documentation when required.

9. Identify and report potential fraud, abuse, or misuse cases in compliance with internal controls and anti-fraud procedures.

10.Contribute to continuous improvement initiatives to enhance claims accuracy, processing speed, and system integrity.

Skills/Qualifications:

· Education & Experience: Bachelor’s degree in Business Administration, Healthcare Management, or a related field; 7+ years’ experience in claims processing or auditing.

· Knowledge & Skills: Medical terminology, claims lifecycle, MS Office proficiency, strong English communication.

· Personal Attributes: Detail-oriented, proactive, organized, able to work under pressure, and self-motivated.

Work Location: In person