As a member of Munich Re the MedNet Global Health Care Solutions L.L.C. is one of the leading managed care service organizations that caters to healthcare needs. We are currently looking for a Officer FWA supports the execution of claims audits and investigations to detect, review, and report potential Fraud, Waste, and Abuse (FWA). The role focuses on assisting in off-site and on-site audits of claims files, ensuring accurate documentation, timely reporting, and compliance with company policies and regulatory requirements. The position contributes to cost containment and payment integrity initiatives under supervision.
Your Job:
• Conduct claims audits to identify potential Fraud, Waste & Abuse (FWA) indicators and ensure compliance with internal policies and controls.
• Prepare audit samples, perform off-site and on-site audits, and maintain accurate audit documentation and case files.
• Investigate discrepancies, escalate suspicious findings to the Team Lead, and monitor pending cases through to resolution and recovery.
• Prepare clear audit summaries, case reports, and final audit reports for management review and case closure.
• Analyze provider irregularities, utilization trends, and payment discrepancies to identify potential risks and improvement opportunities.
• Produce weekly, monthly, quarterly, and annual FWA reports, including audit findings, sampling methodology, recoveries, and outcomes.
• Prepare and submit regulatory FWA reports in accordance with applicable compliance and reporting requirements.
• Maintain audit logs, recovery trackers, and other reporting tools to ensure accurate monitoring of audit activities and performance.
• Collaborate with cross-functional teams, promote knowledge sharing, and provide regular productivity updates to the Team Lead on planned versus completed activities.
Your profile:
Minimum Qualifications and Experience:
• A bachelor s degree in insurance, Medicine, Paramedicine, or related discipline is required.
• Audit and Coding certifications preferred.
• 1-3 years experience within the insurance market (TPA, Insurance Company, or Healthcare Provider).
• Proven experience conducting on-site and off-site audits and handling FWA investigations in the market.
• Experience with data analytics tools.
Is this role a fit for you?
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