Transguard Workforce Solutions is the UAE's leading provider of innovative HR solutions. With over a decade of experience in the region and a knowledgeable team, we offer fully integrated HR services.
We are currently seeking a Compliance Officer - Medical Regulations for one of our very well-known client, to be based in their Abu Dhabi office.
Job Description:
Ensure the Company's medical insurance operations (including but not limited to product design & pricing, underwriting, operations, IT, security & claims management, provider contracting, contracting & relationship with third parties, data privacy, and fraud management) remain compliant with all applicable regulatory frameworks including but not limited to the regulations of the Central Bank of the UAE, DHA, DOH,MOHAP as applicable.
The role establishes independent oversight and remains separate from the day-to-day underwriting/medical approvals/operations to prevent conflicts of interest, ensure compliance and maintain regulatory audit readiness.
Duties:
- Regulatory Liaison, Control & Audit:
- Interpret and map prevailing and new Health Insurance policies, standards, manuals, circulars, and tariff rules to the internal policies/SOPs and notify and advise the Medical Dept. and other Dept.s as required.
- Maintain a Log of all Circulars & Directives and maintain a Compliance Obligations Register and gap log.
- Plan and document routine compliance audits; maintain evidence repositories (policies, contracts, approvals, logs, corrective actions).
- Prepare regulatory submissions and respond to DOH inspections, observations, and remediation plans.
- Act as the primary point of contact with the relevant health authorities and oversee compliance with the prevailing regulations spanning all domains of the Company's medical insurance operations.
2.Oversight of TPAs & Third Parties:
- Establish outsourcing oversight: SLAs, KPIs, audit rights, compliance attestations, and periodic reviews of TPA performance (claims management, provider relations, data privacy, recovery cases).
3.Fraud, Waste & Abuse (FWA):
- Monitor medical claims for suspicious patterns (e.g., overbilling, unbundling, phantom claims) and conduct or support investigations where required.
4.Data Privacy, Security & Retention:
- Ensure all medical data handling complies with data protection laws, healthcare privacy laws and healthcare confidentiality requirements including data retention and data subject right (access/correction/withdrawal where legally permissible).
- Validate data flows with TPAs/IT for secure processing, storage, and any cross-border transfers only under allowed exceptions/approvals.
5.SOP & Policy Review:
- Audit the Company's medical insurance operations across all domains to ensure relevant teams to ensure they follow filed Terms & Conditions, approved schedules of benefits, and internal procedures in line with the prevailing regulations.
6.Regulatory Reporting & Licensing
- Maintain a Log of all the Regulatory reporting Calendar.
- Check/evaluate the accuracy of the Regulatory reports and ensure all relevant teams submit accurate reports timely.
- Submit reports to the Regulators.
- Conduct timely renewal of Health Insurance regulators licenses.
Educational Qualification:
- Bachelor's in Business, Law, or Healthcare Management.
- Minimum 5-10 years experience working in Compliance roles specifically within a Health Insurance Company in the U.A.E.
- Preferred Certifications:: ICA (International Compliance Association) or CFE (Certified Fraud Examiner).
