Medical Provider Performance Executive

Role overview

Investigation and performance duties

• Detect and prevent fraud, abuse, and waste involving medical providers in allocated regions or countries; use data mining and analysis to investigate provider claims.
• Support savings targets set by the Global Head of MPM and support the Medical Provider Performance Manager with administration and fraud-prevention work.
• Review files, gather information, and collect evidence; document findings to substantiate meritorious claims, deny unjustified claims, recover inappropriate payments, or recommend action.
• Assess investigation scope and methodology and prepare comprehensive investigative reports and analysis.
• Participate in onsite audits, in-house claims audits, and mystery-shopping campaigns.
• Collaborate with legal, finance, claims operations, clients, and providers; consult legal and regulatory authorities where cases may involve legal action.
• Ensure periodic dashboards are generated and participate in specialized procurement-related projects and assignments.
• Maintain provider relationships with the MPM team and preserve the reputation of the company, beneficiaries, payers, and other parties.

Qualifications and experience

• Medical background as an MBBS doctor, nurse, or paramedic.
• Coding certification such as CPC, CPMA, COC, or CCS.
• Insurance-industry experience with claims-cycle management.
• Expertise in Excel, Power BI, and data analytics, as well as general industry trends.
• Thorough knowledge of insurance fraud types, investigation strategies and techniques, and applicable federal and state regulations.

Professional capabilities

• Strong interpersonal and relationship skills and excellent written and verbal communication for interviews and correspondence.
• High integrity, dependability, accountability, and confidentiality in handling personal information.
• Ability to analyze data and interpret results, adapt to changing demands, treat people respectfully, collaborate, and provide customer service.
• Ability to work independently with minimal supervision and exercise judgment and initiative in sensitive investigations.

Workplace activities

• The role includes participation in onsite audits and in-house claims audits.

Position details