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.

Claims Integrity