Specialist/Manager

Description

Job Title

Specialist/Manager

Location

AE

Organization Name

Medical Claims Audit

Department Description

Brief Description

Detailed Description

To ensure the integrity of medical claims throughstructured healthcare provider audits, fraud waste and abuse (FWA)identification, and recovery of incorrectly paid claims. This role deliversactionable audit findings, corrective measures, and documented controls thatprotect the organization's financial position and claims quality

Job Requirements

HCP Profiling & Billing Pattern Analysis

Drive regular analysis of healthcare provider billingmethodologies to identify outliers across benefit codes, specialties, and costpatterns.

Ensure findings are documented accurately andcommunicated to concerned providers with defined corrective measures andtimelines.

Medical Provider Audit Execution

Deliver structured medical audits of healthcare serviceproviders in line with approved FWA audit frameworks and organizationalprotocols.

Ensure all audit activities and business decisions aredocumented professionally with appropriate confidentiality and audit trailstandards.

Audit Reporting & Recovery

Deliver final audit reports based on findings andinvestigations, clearly outlining observations, root causes, and recommendedcorrective adjustments.

Drive follow-up with providers on audit findings toensure corrective adjustments and recoveries are initiated and closed withinagreed timelines.

Claims Cycle & Billing Trend Knowledge

Maintain deep understanding of all policies andprocedures related to the claims cycle to effectively identify persistentissues and provider billing trends.

Ensure continuous learning and knowledge application onevolving billing practices, regulatory updates, and FWA investigationtechniques.

Data Analysis & Audit Sampling

Drive the use of data analytics and statistical methodsto identify high-risk providers and prepare audit samples for investigation.

Ensure audit data is sanitized, analysed, and presentedin clear and structured formats that support operational and managementdecision-making

Additional Details

Education

Bachelor’s degree in healthcare administration, MedicalSciences, Business Administration, or a related field

Professional certification in medical auditing, coding,or fraud investigation is an advantage

Required Experience

3-5 years of experience in medical claims auditing, fraud detection, or healthcare provider management

Hands-on experience with HCP billing patterns, FWA identification, and recovery processes

Proficiency in MS Office — particularly Excel and PowerPoint — for data analysis and reporting

UAE driving license is an added advantage for on-site provider audits

Additional Details

Medical Claims Auditing – Delivers structured FWA audits of healthcare providers in line with regulatory and organizational standards

HCP Profiling & Billing Analysis – Identifies outliers, billing anomalies, and FWA patterns through systematic provider data analysis

Data Analysis & Statistical Methods – Enables accurate audit sampling and trend identification through strong analytical and datamining skills

Audit Reporting & Documentation – Ensures professional, confidential, and complete documentation of audit findings and corrective actions

Claims Cycle Knowledge – Maintains deep understanding of claims processes and billing standards to detect persistent issues effectively

MSOffice Proficiency – Ensures efficient data analysis, reporting, and audit presentation through advanced Excel and PowerPoint skills

How To Apply

Amount of Travel

Work At Home

Skills

SkillMinimum LevelMaximum LevelDesirabilityNo results found.