Pharmacy Claims Adjudication Executive

métier - Strategic HR Solutions; Dubai; On-site; AED 201,000 - 312,000; Full time

Job summary

métier - Strategic HR Solutions is seeking a qualified pharmacy professional to support accurate and timely claims decisions for a leading client in the UAE. The role focuses on adjudicating outpatient pharmacy claims, reviewing pre-authorizations, and coordinating with providers and insurers to ensure compliant decisions. Requirements include a B.

Pharm or Pharm. D. from a recognized institution, UAE-licensure or eligibility, and 3–5 years experience in pharmacy or insurance adjudication.

Qualifications

• Experience in pharmacy claims adjudication and medical coding.
• Strong understanding of UAE health insurance and pharmacy regulations.
• Excellent analytical, documentation and attention-to-detail skills.

Responsibilities

• Review and adjudicate outpatient pharmacy claims for medical necessity, eligibility, and policy coverage.
• Verify prescriptions, medicines, dosage, quantity, formulary status, limits, and applicable policy terms.
• Identify duplicate, inappropriate, excessive, or potentially fraudulent pharmacy claims.
• Apply policy terms, medical guidelines, formularies, and insurer rules.

Skills

Pharmacy claims adjudication

Medical coding

Policy interpretation

Analytical skills

Documentation

Education

B. Pharm / Pharm. D. from a recognized institution

Job description

métier - Strategic HR Solutions is hiring a ???????????????????????????????? ???????????????????????? ???????????????????????????????????????????????? ???????????????????????????????????? for one of our leading clients in the UAE.

We are looking for a qualified pharmacy professional with experience in pharmacy claims adjudication and medical insurance to support accurate and timely claims decisions.

???????????? ????????????????????????????????????????????????????????????????:

• Review and adjudicate outpatient pharmacy claims for medical necessity, eligibility, and policy coverage. Verify prescriptions, medicines, dosage, quantity, formulary status, limits, and applicable policy terms. Identify duplicate, inappropriate, excessive, or potentially fraudulent pharmacy claims. Apply policy terms, medical guidelines, formularies, and agreed insurer rules.
• Review pre-authorization requests for high-cost and specialty medications, where applicable.
• Coordinate with providers, pharmacists, insurers, and medical teams for clarification and additional information.
• Ensure accurate, objective, and timely claim decisions while maintaining proper documentation.

???????????????????????????????????????????????????????? & ????????????????????????????????????????:

• B. Pharm / Pharm. D. from a recognized institution.
• UAE-licensed or eligible pharmacist preferred, particularly for clinical review responsibilities.
• 3-5 years of experience in pharmacy, medical insurance claims, hospital pharmacy, or insurance adjudication.
• Experience in pharmacy claims adjudication and medical coding is preferred.
• Knowledge of UAE health insurance, pharmacy claims, and medication regulations.
• Strong understanding of insurance policies, formularies, exclusions, co-payments, limits, and prior authorization.
• Strong analytical, documentation, and attention-to-detail skills.