Claims Integrity

8 months ago


Riyadh, Saudi Arabia Bupa Arabia Full time

Carry out FWA activities to achieve target forecasting and resolve identified business needs within the agreed timescale and quality standards

Collecting the best evidence of the fraudulent act
- Ensure the decisions are according to the best medical standards and agreement terms & conditions in order to prevent abuse, fraud, and overtreatment.
- Assures that each case has been processed according to the checklist of steps.
- Achieve the monthly and yearly target of cases, activities and planned actions.
- Manage the claims integrity activities to ensure all investigations and results align with the planned strategies and serve the organization's goals.

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

Reporting and file-keeping
- Maintain and update the spreadsheet of listed providers
- Initiate the documentation required for the decided actions
- Update the fraud report and dashboard
- Prepare a separate file for each case to include the analysis, evidences, financial figures, and actions taken

Monitoring and progress
- Monitor the identified providers' trends on a monthly basis

**Skills**:

- Ability to conduct business in the English language.
- Analysis skills.
- Strong communication skills.
- Ability to work under pressure.

**Education**:
MBBS (Bachelor of Medicine & Surgery) with some expertise of Insurance is preferred



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