Responsibilities

Fraud, abuse, and waste detection and prevention from medical providers for allocated regions/countries

Data mining and data analysis are required for conducting investigations on provider claims

Support and drive the savings target strategy as set by the global head of MPM

Review files, gather information, collect evidence to detect fraud and abuse on claims

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

Participate in onsite audits, in-house claims audit, and mystery shopping campaigns

Support the Medical Provider Performance Manager with all administration and support tasks to drive fraud detection and prevention

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

Prepare comprehensive investigative reports and analysis

Collaborate and communicate internally with associated departments, i.e., legal, finance, claims operations, as well as external clients and providers

Consult with legal and regulatory authorities for cases that may involve legal action

Manage and ensure generation of periodic dashboards

Participate in specialized projects and assignments related to procurement, as required

Maintain provider relationships in coordination with MPM team

Use judgment, diplomacy, and confidentiality with respect to the complete procurement process, ensuring integrity

Preserve the reputation of the company, beneficiaries, payers, and all other parties involved

Requirements

Medical background (MBBS doctor, nurse, paramedic)

Coding certification like CPC (Certified Professional Coder), CPMA (Certified Professional Medical Auditor), COC (Certified Outpatient Coder), CCS (Certified Coding Specialist)

Work experience in insurance industry with claim cycle management

Expertise in Excel, Power BI, data analytics

Expertise in general industry trends

A thorough knowledge of the various types of insurance fraud and the strategies and techniques used in their investigation and of federal and state regulations

Strong interpersonal and relationship skills

Excellent written and verbal communication skills used for interviewing and corresponding with claimants, attorneys, doctors, law enforcement, etc.

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

Ability to adapt, meet the changing demands of work environment, any delays or other unexpected demands

Ability to treat people with respect under all circumstances, instill trust in others besides upholding the values of the organization

Ability to collaborate and work with internal and external colleagues to successfully complete the defined tasks and provide superior customer service