RCM Specialist

Job Summary

RCM Team Leader / Senior RCM Specialist with strong exposure to the healthcare and pharmaceutical sector. The ideal candidate will have extensive hands-on experience in revenue cycle management, insurance contracts, UAE healthcare regulations (HAAD/DOH, DHA, MOH), and pharmacy claims adjudication. This role will also play a key role in facility empanelment’s and onboarding new insurance networks to support business expansion.

Key Responsibilities

• Lead and manage end-to-end Revenue Cycle Management (RCM) activities including eligibility, claims validation, claims submission, resubmissions, denials management, reconciliation, and collections.
• Supervise and mentor RCM team members to ensure high productivity, accuracy, and compliance.
• Ensure adherence to DOH (must) , DHA, and MOH regulations, payer policies, and insurance guidelines.
• Manage and review insurance contracts, tariff structures, negotiation, legal documents, and empanelment.
• Lead facility empanelment processes with insurance companies and TPAs, including documentation, licensing validation, tariff setup, and system configuration.
• Oversee pharmacy and medicine claims adjudication, ensuring correct application of coverage rules, exclusions, prior approvals, and formulary guidelines.
• Analyze and resolve complex claim denials related to medicines, coding, pricing, and policy interpretation.
• Liaise with insurance providers, TPAs, internal pharmacy teams, and medical centers to resolve escalated issues.
• Identify process gaps and implement continuous improvement initiatives to optimize revenue and compliance.
• Support audits, payer reviews, and regulatory inspections related to claims and billing.

Required Qualifications & Experience

• Minimum 5+ years of experience in Revenue Cycle Management within the healthcare industry, preferably in pharmacy or pharmaceutical claims.
• Proven experience in a senior or team leadership role within RCM.
• Strong hands-on experience with insurance contracts management and payer negotiations.
• Proven expertise in facility empanelment, insurance onboarding, and payer network management.
• Excellent working knowledge of DOH, DHA, and MOH regulations.
• Solid understanding of pharmacy operations, medicines adjudication rules, formularies, prior authorization processes, and coverage criteria.
• Good proficiency in MS Excel (pivot tables, VLOOKUP/XLOOKUP, data analysis) and Microsoft Office.
• Strong experience working with RCM systems, HIS, pharmacy systems, and insurance portals.
• Excellent analytical, problem-solving, and decision-making skills.

Preferred Skills

• Experience in UAE insurance market.
• Ability to handle high-volume claims environments with accuracy and efficiency.
• Good team leading, training, and coaching capabilities.
• Attention to detail with a strong compliance mindset.

Medical background is a must. Preferrable pharmaceutical