Responsibilities

Collaborate with the global head of Medical Provider Management (MPM) to set and support the achievement of savings targets.

Develop and implement strategies for fraud, abuse, and waste detection and prevention among medical providers in assigned regions/countries.

Monitor and review provider claims to detect inconsistencies and irregularities.

Assess the scope and determine the methodology needed to carry out an efficient investigation.

Data mining and data analysis for providers under investigations.

Participate in onsite audits, in-house claims audit, offsite audits with data trending, and mystery shopping campaigns to assess provider compliance to ethical practices and to detect fraudulent activities.

Document all evidence obtained in the investigation in order to substantiate meritorious claims, to deny unjustified claims, to recover inappropriate payments, or to recommend action against responsible parties.

Communicate findings and recommendations to the legal, finance, claims operations, and other associated departments, as well as to external clients and providers.

Consult with legal and regulatory authorities as necessary, particularly in cases involving potential legal action.

Ensure all communications and interactions are conducted with judgment, diplomacy, and confidentiality to maintain the integrity of the procurement process.

Provide regular feedback to Medical Provider Performance Manager for the ongoing audit activities and provider negotiations.

Manage the generation and review of periodic dashboards and other monitoring tools to track the effectiveness of fraud and abuse prevention measures.

Maintain and strengthen relationships with medical providers in coordination with the MPM team.

Represent the company's reputation and values, ensuring that all actions align with ethical standards and protect the interests of beneficiaries, payers, and other stakeholders.

Requirements

Medical background (MBBS doctor).

Coding certification (preferred).

Proven experience in fraud detection, data analysis, and investigative methodologies.

Strong strategic planning and organizational skills.

Effective communication and reporting skills.

Ability to work collaboratively across departments.

High level of integrity and professionalism in handling sensitive information.

Expertise in Excel, Power BI, and data analytics.

A high degree of integrity, dependability, accountability, and confidentiality is required for handling information that is considered personal and confidential.

Ability to analyze data and interpret results.