Claims Integrity

#### **Job Description** 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. #### **Skills** * 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.