Medical Claims Audit Manager

**Job Overview:** The Medical Claims Provider Audit Manager is responsible for leading and managing all aspects of provider claims audits to ensure compliance with internal policies, payer requirements, and regulatory standards.

This role plays a critical part in minimizing financial risk by detecting fraudulent, wasteful, or abusive billing behaviors and driving systemic improvements across claims operations.

The manager will oversee a team of auditors, liaise with healthcare providers and regulatory bodies, and play a key role in system enhancement, reporting, and strategic planning related to provider utilization and claims integrity.

· Lead the identification and investigation of abnormal provider utilization patterns through comprehensive claims data analysis and understand provider’s utilization behavior to initiate audits on fraud/waste/ abusive claims.

· Based on the audit outcomes, possible system controls requirements and recommendations should be provided to all the internal stakeholders.

· Facilitate in preparing monthly audit action plans, periodic fraud/waste/abuse reports to regulators, client specific quarterly/ annual utilization reports and payment order assistance’s as and when required.

· Report providers over utilization and audit results with recommend changes in standard operational procedures and claims adjudication process.

Examine existing system controls; liaise with internal stakeholders and recommendations for better enhancements.

· Comply with all the relevant organization/ regulatory rules, regulations, standards, policies and procedures & reports.

Ensure all audit activities comply with the regulatory requirements and healthcare providers audit standards should be adhered.

· Assist in the conduct to delegated entities audits and prepares written audit results.

Actively audit providers for contentious claims and admissions to identify fraud, abuse and utilization trends through surprise visits/regular audits and random concurrent reviews

· Provide guidance and support to auditors and other team members; ensure audit procedures adhere to all relevant healthcare regulations and industry best practices.

· Maintain strong, professional relationships with providers through regular communication and issue resolution.

· Attend regulatory and compliance meetings and represent the audit department in external and internal forums.

· Foster a culture of continuous improvement by staying updated on regulatory changes, audit techniques, and healthcare trends.

· Supervise special projects and other related duties as assigned by leadership.

**Qualification:** Medical / Para-medical professionals with vast experience in healthcare provider’s audits and expert in relevant claim adjudication/ medical coding/ billing system

**Experience:** Minimum 5 years of experience in healthcare provider Audit from major TPA or Insurance companies in UAE