Pharmacy Claims Adjudication Executive
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Key skills for this role
Role Overview
Pharmacy Claims Adjudication Executive role supporting accurate and timely pharmacy claims decisions for a UAE client.
The role is intended for a qualified pharmacy professional with pharmacy claims adjudication and medical insurance experience.
Key Skills for This Role
Full Job Posting
Role Overview
Pharmacy Claims Adjudication Executive role supporting accurate and timely pharmacy claims decisions for a UAE client.
The role is intended for a qualified pharmacy professional with pharmacy claims adjudication and medical insurance experience.
Key Responsibilities
- Review and adjudicate outpatient pharmacy claims for medical necessity, eligibility, and policy coverage.
- Verify prescriptions, medicines, dosage, quantity, formulary status, limits, and policy terms.
- Identify duplicate, inappropriate, excessive, or potentially fraudulent claims.
- Apply policy terms, medical guidelines, formularies, and insurer rules.
- Review pre-authorization requests for high-cost and specialty medications where applicable.
- Coordinate with providers, pharmacists, insurers, and medical teams for clarification.
- Make accurate, objective, and timely claim decisions while maintaining documentation.
Qualifications and Experience
- B. Pharm or Pharm.D. from a recognized institution.
- 3–5 years of experience in pharmacy, medical insurance claims, hospital pharmacy, or insurance adjudication.
- Knowledge of UAE health insurance, pharmacy claims, and medication regulations.
- Strong understanding of insurance policies, formularies, exclusions, co-payments, limits, and prior authorization.
- UAE pharmacist licensing or eligibility is preferred for clinical review responsibilities.
- Pharmacy claims adjudication and medical coding experience is preferred.
- Strong analytical, documentation, and attention-to-detail skills.
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