Medical Provider Performance Executive

Role overview

Responsibilities

• Detect and prevent fraud, abuse, and waste involving medical providers in allocated regions or countries; mine and analyze provider-claims data.
• Support savings-target strategy and assist the Medical Provider Performance Manager with administration and fraud-prevention activities.
• Review files, gather information, and collect evidence; document findings to substantiate claims, deny unjustified claims, recover inappropriate payments, or recommend action.
• Participate in onsite audits, in-house claims audits, and mystery-shopping campaigns; assess investigation scope and methodology.
• Prepare investigative reports and analysis, and manage periodic dashboard generation.
• Coordinate with legal, finance, claims operations, clients, and providers; consult legal and regulatory authorities when cases may involve legal action.
• Maintain provider relationships with the MPM team and participate in procurement-related projects as required.
• Use judgment, diplomacy, and confidentiality in procurement processes and preserve the reputation of the company, beneficiaries, payers, and other parties.

Requirements

• 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.
• Knowledge of industry trends, types of insurance fraud, investigation strategies and techniques, and federal and state regulations.
• Strong interpersonal and relationship skills, with excellent written and verbal communication for interviewing and correspondence.
• Integrity, dependability, accountability, and confidentiality in handling personal information.
• Ability to analyze data, interpret results, adapt to changing demands, and collaborate with internal and external colleagues.