Supervisor Medical Fraud, Waste & Audit
Posted on :
09-07-2025
Employer Active
1 Vacancy
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Job Description
Job Purpose:
To lead and manage medical claim audits fraud investigations and risk mitigation strategies by leveraging clinical and analytical expertise to detect prevent and recover fraudulent claims. Ensure cost containment compliance with health insurance guidelines and maintain the integrity of provider networks.
Key Responsibilities:
- Conduct in-depth audits of inpatient and outpatient claims to identify irregularities and fraudulent patterns.
- Investigate suspicious claims from providers or insured members and provide reports with findings and recommendations.
- Perform retrospective reviews of claims and recommend recovery actions where applicable.
- Utilize clinical background and health policy knowledge to evaluate the appropriateness of treatments and billing.
- Work closely with medical providers claim processing teams and IT to detect fraud and mitigate risks.
- Analyze large volumes of claims data to identify trends and generate actionable insights.
- Prepare detailed investigation and audit reports including recovery amounts analysis findings and fraud prevention measures.
- Develop and maintain dashboards for savings turnaround time (TAT) and fraud indicators.
- Assist in provider evaluation credentialing and price negotiations based on performance audit findings and service delivery.
- Recommend exclusion or blacklisting of non-compliant providers based on audit outcomes.
- Recommend and support the implementation of automation tools and controls to enhance fraud detection capabilities.
- Contribute to policy updates and SOP enhancements to improve audit and investigation standards.
- Train and guide junior auditors or claim analysts in fraud indicators and audit methodology.
- Actively participate in cross-departmental meetings and share best practices.
Requirements
Qualifications & Certifications:
- MBA in Hospital Management or equivalent
- B.A.M.S. (Bachelor of Ayurveda Medicine and Surgery) or Medical Graduate (Alternative or Allopathic stream)
- Certification in Fraud Detection Health Insurance or Risk Management
Experience:
- Minimum 5 7 years in medical claims audits or insurance fraud detection.
- Proven track record of successful fraud investigations and recoveries.
- Experience working in GCC healthcare insurance systems is preferred.
Key Skills:
- Medical auditing & claims investigation
- Fraud detection and analytics
- Data analysis & report writing
- Strong knowledge of medical terminology coding and treatment protocols
- Network/provider management
- Regulatory compliance in health insurance
- Excellent communication negotiation and stakeholder handling skills
- Time management and ability to handle sensitive cases with confidentiality.
Employment Type
Full Time
Key Skills
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