Claims Integrity
8 months ago
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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