Senior Health Benefits Claims Specialist

Job Title: Senior Health Benefits Claims Specialist

Location: United Arab Emirates (Remote)

Employment Type: Full-Time

Work Arrangement: 100% Remote — Work From Home

Level: Senior

About the Role

We are seeking an experienced Senior Health Benefits Claims Specialist to oversee the review, assessment, processing, and resolution of health insurance and employee medical benefit claims. The successful candidate will ensure claims are handled accurately, efficiently, and in accordance with applicable policy terms, contractual obligations, and regulatory requirements. This fully remote role involves claims evaluation, benefits verification, medical documentation review, payment reconciliation, dispute resolution, and coordination with healthcare providers, insurers, third-party administrators, and internal stakeholders.

Key Responsibilities

• Review and assess health insurance claims to determine eligibility, coverage, benefit limits, and payment amounts.
• Verify member eligibility, policy validity, coverage dates, exclusions, deductibles, co-payments, and annual benefit limits.
• Evaluate medical claims documentation, invoices, treatment records, and supporting evidence for completeness and consistency.
• Apply relevant policy provisions, benefit schedules, contractual terms, and claims processing guidelines.
• Investigate complex, high-value, disputed, or escalated claims and recommend appropriate resolutions.
• Coordinate with healthcare providers, hospitals, clinics, insurers, and third-party administrators to clarify claim details and resolve discrepancies.
• Review medical billing information and identify duplicate charges, coding inconsistencies, unusual billing patterns, and potential overpayments.
• Assess claims requiring additional medical or technical review and coordinate referrals to qualified clinical professionals when necessary.
• Monitor claims processing timelines and ensure cases are resolved within established service-level agreements.
• Investigate rejected, delayed, partially paid, and appealed claims and communicate decisions clearly to relevant stakeholders.
• Support claims reconsideration and appeals by reviewing documentation, policy terms, and the rationale for previous decisions.
• Reconcile claims payments, adjustments, recoveries, and outstanding balances with relevant financial records.
• Identify potential fraud, waste, abuse, and suspicious billing patterns, escalating concerns through established investigation procedures.
• Maintain accurate claims records, case notes, supporting documents, and audit trails within approved claims management systems.
• Prepare claims performance reports covering processing volumes, turnaround times, payment accuracy, appeals, and outstanding cases.
• Recommend improvements to claims workflows, quality assurance procedures, and operational controls.
• Support internal audits, regulatory reviews, and compliance assessments by providing relevant claims documentation.
• Provide technical guidance and mentoring to junior claims specialists and help maintain consistent decision-making standards.
• Handle sensitive health and personal information in accordance with applicable privacy, confidentiality, and information security requirements.

Qualifications and Experience

• Bachelor's degree in Health Administration, Insurance, Healthcare Management, Finance, Business Administration, or a related discipline.
• Significant experience in health insurance claims processing, medical benefits administration, healthcare reimbursement, or third-party claims administration.
• Strong understanding of health insurance policies, benefit structures, coverage rules, exclusions, and claims adjudication procedures.
• Experience reviewing medical invoices, treatment documentation, provider bills, and supporting claims records.
• Knowledge of medical billing practices, diagnosis and procedure coding concepts, and healthcare reimbursement principles.
• Familiarity with health insurance operations and applicable UAE health insurance requirements.
• Experience managing complex claims, escalations, appeals, reconsiderations, and payment disputes.
• Understanding of claims quality assurance, fraud detection, overpayment recovery, and operational risk controls.
• Familiarity with claims management platforms, insurance administration systems, and electronic document management tools.
• Proficiency in Microsoft Excel and claims reporting or data analysis tools.
• Strong analytical skills and the ability to interpret policy provisions and complex claims documentation.
• Excellent written and verbal communication skills for dealing with providers, insurers, members, and internal teams.
• High attention to detail and the ability to maintain accuracy when processing large volumes of claims.
• Strong organizational skills and the ability to manage competing priorities in a fully remote environment.
• Professional certifications in health insurance, claims administration, medical billing, or healthcare management are an advantage.

What We Offer

• A fully remote, work-from-home position within the UAE employment context.
• Competitive compensation based on experience, qualifications, and relevant industry expertise.
• Opportunities to contribute to health insurance operations and claims quality improvement.
• Professional development in claims adjudication, healthcare reimbursement, and insurance compliance.
• A collaborative working environment focused on accuracy, service quality, confidentiality, and continuous improvement.

How to Apply

Interested candidates should submit an updated CV highlighting their experience in health insurance claims, medical benefits administration, claims adjudication, provider coordination, and dispute resolution.

Application Subject: Application – Senior Health Benefits Claims Specialist (UAE Remote)

• Candidates should confirm applicable employment arrangements, residency requirements, and work authorization before accepting an offer. This role is designed for remote claims assessment, documentation review, reporting, and virtual coordination. Clinical opinions, medical necessity determinations requiring licensed clinical judgment, and regulated insurance decisions must be handled or approved by appropriately qualified and authorized professionals where required by applicable law.