MAIN PURPOSEOF THE JOB:The primary responsibility of this role is to investigate and analyse claims data to identify potential instances of fraud, waste, and abuse.KEY ACCOUNTABILITIES:· Analyse claims data to identify patterns and anomalies that may indicate potential fraud, waste, and abuse.· Investigate suspicious claims and conduct thorough reviews to determine validity and accuracy.· Collaborate with internal teams, including claims processing, legal and compliance to gather information and evidence related to potentially fraudulent activities.· Communicate with external stakeholders such as providers to gather additional information and support investigation.· Document findings and prepare detailed reports on suspected fraudulent activities for further action.· Support leadership in formulation and implementation of strategies to prevent and detect fraudulent activities within the claims process.· Stay informed about industry trends, regulations and best practices related to fraud waste and abuse detection and prevention.·KEYSTAKEHOLDERS:Internal: Claims Leadership Team,External: Network Partners, Clients, DistributorsQualificationsEXPERIENCE & QUALIFICATION· Bachelor’s degree in related medical field with minimum of 2 years related experience in fraud, waste and abuse investigations or equivalent claims processing/adjudicating/auditing experience is an advantage.· Experience in fraud detection, investigation, or claims analysis, preferably in the healthcare or insurance industry.· String analytical and critical thinking skills with the ability to interpret data and identify irregularities.· Knowledge of health care billing and coding practices as well as regulatory requirements related to claims processing.· Excellent communication and interpersonal skills with the ability to collaborate with cross functional teams and external stakeholders.· Understanding of legal and ethical considerations related to fraud investigation and compliance.· Experience in conducting interviews and interrogations related to fraud investigations.
