Claims Integrity

Job Description

Perform detailed review and analysis of FWA-related cases, alerts, claims patterns, and emerging market trends to ensure accurate assessment, evidence documentation, decision support, recovery follow-up, and feedback into Claims Integrity controls and process improvement initiatives.

FWA Case, Alert & Pattern Review

• Review FWA-related cases, alerts, claims patterns, and suspicious provider/member behaviours.

• Assess claim details, medical justifications, billing patterns, and supporting evidence to identify potential FWA concerns.

• Document findings clearly to support decisions, recoveries, escalations, or further review.

Negotiating the fraudulent cases

• Arrange the collected data for negotiation and decision-making

• Arrange the collected evidences

• Discuss the evidences with the providers Relation Team for substantiation

• Negotiate with the provider relation team for the needed recovery that satisfies the target forecasting

• Complete the necessary reports and file for escalation to regulators

Market Trend & Behaviour Identification

• Analyze repeated claims behaviours, provider trends, market practices, and emerging FWA patterns.

• Identify new or evolving abuse behaviours that may require new controls, rules, reviews, or process changes.

• Provide observations and feedback to support enhancement of Claims Integrity controls and detection logic.

Recovery Support & Process Improvement Feedback

• Support recovery follow-up by providing validated findings, evidence, and business rationale.

• Coordinate with relevant stakeholders to ensure review outcomes are actioned appropriately.

• Provide feedback on operational gaps, false positives, review challenges, and improvement opportunities.

Skills

• 2 Years medical practice and Insurance

• Analytical and investigative skills, with the ability to identify suspicious patterns,

• emerging market trends, and potential control gaps.

• Documentation skills, including the ability to prepare case summaries, evidence packs, findings, and decision-support inputs.

• Problem-solving skills with the ability to provide practical feedback for improving Claims Integrity controls, detection logic, and operational processes.

• Communication and stakeholder coordination skills, especially with Claims Integrity, medical, provider management, recovery, and operational teams.

• Bachelor's degree in Medicine (M.B; B.S./M.D or equivalent)

• Understanding of claims integrity, FWA, medical audit, claims operations, or healthcare insurance controls.

• Ability to review and analyse FWA-related cases, alerts, claims patterns, provider behaviours, and supporting evidence.

• Attention to detail and commitment to accuracy, evidence quality, consistency, and auditability of review outcomes.

• Working knowledge of claims systems, case management tools, dashboards, Excel, or reporting tools is preferred.

• Digital proficiency, with the ability to effectively use claims systems, case management tools, dashboards, Excel, and reporting platforms to review cases, analyse patterns and support process improvements.