Specialist - Insurance Programs Management; UAE Nationals

Qualification required:
Masters and Bachelor in Medical field

Experience required : 8-10 years of In the Medical field ( medical auditing )

Nationality:
Preferably Emirati, but other nationalities are not objectionable

• Review all allegations of potential Fraud, Waste and Abuse (FWA).
• Provides recommendations to close inquire or open investigative cases in order to prevent and detect health insurance Fraud, Waste and Abuse (FWA).
• Prepare the annual audit plan pertaining to the facilities that will be audited in the current year.
• Make data analysis, research and review of claims data to identify trends, patterns and emerging issues in healthcare fraud, waste and abuse. All to ensure consistency and completeness.
• Make recommendation on the CPT coding rules for the FWA Tool to create a list of the rules in the tool for easy and early detection.
• Ensure the accuracy and compliance of diagnosis codes, given services & treatments and all medical billing documentation as per regulatory standards.
• Participate and conduct onsite audit visit (once recommended) to investigate of fraudulent, wasteful and abusive activities at healthcare providers and other health insurance parties.
• Review contract terms, medical records, claims history, financial records and other documentation to determine FWA and identify potential patterns.
• Write clear, concise reports about the audit findings; submit it to the line manager.
• Maintain all documentation for Fraud, Waste and Abuse (FWA) cases and update the tracker regularly.
• Follow up with TPA regarding the settlement of recoverable amount or payment plan agreements and track it.
• Communicate with members and parties involved in health insurance related activities routinely regarding issues including investigative findings, recoveries, and educational feedback where appropriate.
• Maintain Confidentiality of the Insurance corporation internal process, information, violations, any findings, stakeholders, documents, plans, …… etc.
• Review, interpret and apply the health insurance law with its decrees in detecting the violations for healthcare providers.
• Ensure reporting for all details and evidences in the post-audit report to be inclusive of the finding’s summary and suggestions for any corrective actions.
• Share knowledge, educate staff and conduct training or workshops once recommended.
• Perform any other duties as assigned by the department’s director based on the authority channel dealt with officially in the Insurance Corporation in the organization.