Manager - Claims Integrity

Perform detailed review and analysis of FWA-related cases, alerts, claims patterns, and emerging market trends to ensure accurate assessment, evidence documentation, decision support, recovery follow-up, and feedback into Claims Integrity controls and process improvement initiatives.

FWA Case, Alert & Pattern Review:

·       Review FWA-related cases, alerts, claims patterns, and suspicious provider/member behaviours.

·       Assess claim details, medical justifications, billing patterns, and supporting evidence to identify potential FWA concerns.

·       Document findings clearly to support decisions, recoveries, escalations, or further review.

Negotiating the fraudulent cases:

·       Arrange the collected data for negotiation and decision-making

·       Arrange the collected evidences

·       Discuss the evidences with the providers Relation Team for substantiation 

·       Negotiate with the provider relation team for the needed recovery that satisfies the target forecasting

·       Complete the necessary reports and file for escalation to regulators  

Market Trend & Behaviour Identification:

·       Analyze repeated claims behaviours, provider trends, market practices, and emerging FWA patterns.

·       Identify new or evolving abuse behaviours that may require new controls, rules, reviews, or process changes.

·       Provide observations and feedback to support enhancement of Claims Integrity controls and detection logic.

Recovery Support & Process Improvement Feedback:

·       Support recovery follow-up by providing validated findings, evidence, and business rationale.

·       Coordinate with relevant stakeholders to ensure review outcomes are actioned appropriately.

·       Provide feedback on operational gaps, false positives, review challenges, and improvement opportunities.

·       2 Years medical practice and Insurance

·       Analytical and investigative skills, with the ability to identify suspicious patterns, 

·       emerging market trends, and potential control gaps.

·       Documentation skills, including the ability to prepare case summaries, evidence packs, findings, and decision-support inputs.

·       Problem-solving skills with the ability to provide practical feedback for improving Claims Integrity controls, detection logic, and operational processes.

·       Communication and stakeholder coordination skills, especially with Claims Integrity, medical, provider management, recovery, and operational teams.

·       Bachelor's degree in Medicine (M.B; B.S./M.D or equivalent)

·       Understanding of claims integrity, FWA, medical audit, claims operations, or healthcare insurance controls.

·       Ability to review and analyse FWA-related cases, alerts, claims patterns, provider behaviours, and supporting evidence.

·       Attention to detail and commitment to accuracy, evidence quality, consistency, and auditability of review outcomes.

·       Working knowledge of claims systems, case management tools, dashboards, Excel, or reporting tools is preferred.

·       Digital proficiency, with the ability to effectively use claims systems, case management tools, dashboards, Excel, and reporting platforms to review cases, analyse patterns and support process improvements.