Responsible for conducting objective, fair, thorough, unbiased and timely investigations of healthcare providers’ performance whilst monitoring best of relationships with all parties.
United Arab Emirates
Medical Provider Management Department
Bachelor Degree in medical is a must.
At least 3 years’ supervisory experience working in a medical provider audit team.
Expertise in general health insurance industry trends and regulations.
Strong analytical & audit skill in medical coding.
A thorough knowledge of the various types of insurance abuse and the strategies and techniques used in their investigation and of federal and state regulations.
Provider Performance Monitoring of medical providers for allocated regions/countries.
Generating saving and recoveries through Provider Performance Monitoring protection and prevention.
Prevent leakages from overutilization by regular monitoring of provider performance.
Data mining and data analysis are required for conducting investigations on provider claims.
Support and drive the savings target strategy as set by the Global Head of MPM.
Support the strategy and processes as outline by the Medical Provider Performance Manager.
Manage onsite campaigns, in-house claims audit and mystery shopping campaigns.
Monitor the team performance and escalate matters timely to the manager.
Review files, gather information, collect evidence to detect any aberrant patterns which lead to deviations from the benchmarks.
Assesses the scope and determine the methodology needed to carry out an efficient investigation.
Prepare comprehensive investigative reports and analysis.
Document all evidence obtained in the investigation in order to substantiate meritorious claims, to deny unjustified claims, to recover inappropriate payments or to recommend action against responsible parties.
Collaborates and communicates internally with associated department’s i.e. legal, compliance, finance, claims operations as well as external clients and providers.
Consults with legal, compliance and regulatory authorities for cases that may involve legal action.
Manages and maintains provider relationship in coordination with MPM team and works within legal, compliance and regulatory framework.
Ensures investigations have a clear, single-focused intent of covering/uncovering and providing necessary facts resolve a claim.
Manages and ensures generation of periodic dashboards to evaluate and monitor claim cost, identify the utilization trends & variances to initiate the audit.
Supports with the development and training of company personnel in analyzing the provider performance monitoring.
Participates in specialized projects and assignments related to procurement, as required.
Uses judgment, diplomacy and confidentiality with respect to the complete procurement process, ensuring integrity.
Preserves the reputation of company, beneficiaries, payers and all other parties Involved. Participates in specialized projects and assignments related to procurement, as required.
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