Manager - Claims & Pre-Authorization
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Key skills for this role
About the Role
Dubai Insurance TPA is seeking a Manager to lead Pre-Authorization and Claims Operations. You will oversee SLA performance, regulatory compliance, quality management, and team development.
Key Skills for This Role
Responsibilities
- Oversee daily PA MENA and Claims Operations to ensure timely work allocation, queue management, backlog control, and delivery against agreed service standards
- Monitor provider call handling performance (ASA, ABN, AHT targets)
- Ensure claims processing targets are achieved (member claims 95% within 5 working days, 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
- Ensure adherence to data protection, authority matrix, payer rules, regulatory requirements, SOPs, and internal governance controls
- Maintain transaction quality through daily and monthly error reviews, root cause analysis, coaching, and corrective action plans
- 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
- Manage workflow prioritization, resource allocation, contingency planning, and business continuity arrangements
- Conduct structured daily huddles, regular one to one check ins, and monthly performance reviews
Requirements
- Minimum 7–8 years of TPA, payer, insurer, or medical operations experience
- 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)
Full Job Posting
Job Purpose
- 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.
Service Delivery, SLA Management & Operational Control
- Oversee daily PA MENA and Claims Operations to ensure timely work allocation, queue management, backlog control, and delivery against agreed service standards.
- Monitor provider call handling performance: ASA target 20 seconds, ABN target 4%, AHT target 360 seconds.
- Ensure claims processing targets: member claims 95% within 5 working days, provider claims 95% within 20 working days.
Governance, Compliance, Quality & Audit Readiness
- Monitor daily inventory, aging cases, pending queues, high risk cases, and backlog trends.
- Ensure adherence to data protection, authority matrix, payer rules, regulatory requirements, SOPs, and internal governance controls.
- Maintain transaction quality through daily and monthly error reviews, root cause analysis, coaching, and corrective action plans.
- 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.
- Monitor and control financial leakage and ex gratia payments.
- Ensure SOPs, desktop procedures, trackers, authority controls, and governance documents are reviewed at least annually.
- Manage workflow prioritization, resource allocation, contingency planning, and business continuity arrangements.
- Maintain operational trackers, team planners, attendance records, leave coverage plans, overtime logs, risk logs, and action trackers.
- Track audit findings, quality issues, compliance gaps, and corrective actions through closure.
People Management, Capability Development & Engagement
- Conduct structured daily huddles, regular one to one check ins, and monthly performance reviews.
- 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.
- Maintain succession readiness and cross skilling plans.
- Promote a culture of accountability, continuous improvement, collaboration, and timely escalation.
Technical & Escalation Management
- 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.
Stakeholder, Client & Provider Support
- Collaborate with Claims, PA, Clinical, Compliance, Client Management, Network, Finance, IT, Quality, TPAs, providers, and other stakeholders.
- Provide accurate ad hoc reports, trend analysis, claims or PA insights, and action plans.
- Represent PA MENA and COE Claims Operations in governance forums, leadership meetings, audit discussions, and service improvement reviews.
Training & Knowledge Management
- Support onboarding, refresher training, policy updates, system training, and external or internal knowledge sharing sessions.
- Translate performance trends, audit learnings, and stakeholder feedback into focused training priorities.
- Maintain team knowledge readiness by ensuring updates on SOP changes, payer rules, coding guidance, regulatory expectations, and system/process changes are cascaded timely.
Process Improvement, Systems & Projects
- 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.
- Contribute to cross functional projects aimed at improving medical operations efficiency, system integration, governance controls, reporting capability, and service resilience.
Knowledge, Skills and Experience
- 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).
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