Overview
Senior Officer – Medical Operations Jobs in Abu Dhabi, UAE at AEGI Holding
About Us:
Alfit is a new insurance venture being launched by AEGI, designed to establish a modern, customer-centric platform within the insurance sector. The business will initially focus on health, life, and travel insurance products, with a clear roadmap for future expansion across additional lines.
As we approach our official launch, we are entering a critical growth phase and are actively building a high-caliber team. We are seeking professionals who are motivated to be part of a next-generation insurance company, combining innovation, operational excellence, and customer focus, led by a leadership team comprising highly respected veterans of the insurance industry.
Job Purpose:
They would be responsible for executing the day-to-day adjudication of medical claims and pre-authorization requests, ensuring alignment with Alfit policies, regulatory requirements and clinical standards. Working closely with appointed TPAs, healthcare providers, insured members and internal departments, the role ensures the timely and accurate processing of claims and approvals, contributing to operational efficiency, cost containment and customer satisfaction. The position plays a key role in maintaining Alfit's compliance, reducing claim rejections, and enhancing the overall member and provider experience.
Job Responsibilities:
1. Claims & Pre-Authorization Processing
• Counter-review and assess medical claims and pre-authorisation requests in line with Alfit policies, the Table of Benefits, clinical guidelines and UAE regulatory requirements.
• Manage a portfolio of claims and approvals, prioritising based on clinical urgency, financial risk and policy terms.
• Verify eligibility, correct coding (ICD-10, CPT) and documentation completeness before final adjudication.
• Coordinate with TPAs and healthcare providers to resolve queries, disputes and reconsiderations in a timely and professional manner.
• Contribute to Fraud, Waste & Abuse (FWA) monitoring activities and flag suspicious patterns for further investigation.
• Escalate complex, high-value or disputed claims to the Team Leader and CMO with documented analysis and recommendations.
2. Customer Orientation – Voice of Customer & Complaint Contribution
• Contribute to Alfit's Voice of Customer (VoC) framework by surfacing member and provider feedback collected through claims and pre-authorisation touchpoints.
• Contribute to the investigation, resolution and root-cause analysis of Medical Operations-related complaints, as per Alfit's Complaints Management framework.
• Promote customer-first behaviours in every interaction and advocate for the member and provider perspective in cross-functional discussions.
3. Compliance Orientation
• Ensure all claims and approvals handling meets CBUAE, Health-related regulations and Alfit's internal policies.
• Maintain accurate, audit-ready records of adjudication decisions, communications and supporting documentation in the relevant systems.
• Adhere to approved clinical guidelines, SOPs and regulatory guidance at all times, and flag any deviation or ambiguity to the Team Leader.
• Support internal and external audits by providing documentation, addressing queries and executing corrective actions.
4. Performance & Quality
• Meet individual service-delivery targets, including Productivity, TAT, QA, Financial Variance and CSAT.
• Participate in quality calibration sessions and act on QA feedback to continuously improve service delivery.
• Use the core insurance management system, TPA platform, telephony, CRM and knowledge-management tools effectively to deliver consistent service.
• Contribute to the maintenance of FAQs, knowledge-base articles and clinical adjudication job aids.
• Maintain clear communication with internal stakeholders (peer Operations sub-units, Underwriting, Finance, IT, Compliance) and external parties (TPAs, brokers, providers, members).
5. Continuous Improvement
• Participate in the development of Business Requirements and the conduction of User Acceptance Testing (UAT) for new system features, fixes and enhancements affecting the claims and pre-authorization workflows.
• Support the testing and rollout of innovative digital solutions (e.g. Claim Risk AI, automated adjudication rules) and provide structured business feedback.
• Identify recurring denial patterns, bottlenecks and inefficiencies, and propose process, system or clinical-rule improvements to the Team Leader and CMO.
• Contribute to the design and refinement of claims and pre-authorization workflows in collaboration with Operations, Underwriting, IT and the provider network.
6. Overarching Accountabilities
• Adhere to Alfit's standards, policies and regulatory requirements at all times.
• Embody Alfit Insurance's core values and promote customer-first behaviours.
• Support new-joiner onboarding and share subject-matter knowledge with peers.
• Undertake additional administrative and operational tasks as required to ensure business continuity.
Indicative KRA’s / Budgetary and Revenue Responsibilities
• Claim and pre-authorisation TAT versus SLA
• Accuracy of adjudication decisions and audit sampling results
• Claim rejection and denial rates
• Contribution to medical cost-containment and FWA initiatives
• Documentation completeness and audit readiness
• Contribution to Medical Operations-related complaint resolution and root-cause analysis
• Audit findings closure
Title: Senior Officer – Medical Operations
Company: AEGI Holding
Location: Abu Dhabi, UAE
