Roles and responsibilities
ob Responsibilities / What you do:
- Fraud Abuse and Waste detections and prevention from Medical providers for allocated regions/countries
- 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
- Review files, gather information, collect evidence to detect fraud and abuse on claims
- 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
- Participate in onsite Audits, in-house claims audit and Mystery shopping campaigns
- Support the Medical Provider Performance Manager with all administration and support tasks to drive Fraud detections and prevention.
- Assesses the scope and determine the methodology needed to carry out an efficient investigation.
- Prepare comprehensive investigative reports and analysis
- Collaborates and communicates internally with associated department’s ie legal, finance, claims operations as well as external clients and Providers.
- Consults with legal and regulatory authorities for cases that may involve legal action.
- Manages and ensures generation of periodic dashboards
- Participates in specialized projects and assignments related to procurement, as required.
- Maintains provider relationship in coordination with MPM team
- 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.
Key requirement / What you bring:
- Medical Background (MBBS doctor/Nurse/Paramedic)
- Coding Certification like CPC(Certified professional Coder), CPMA (Certified Professional medical Auditor, COC (Certified Outpatient Coder), CCS (certified Coding Specialist)
- Work experience in insurance industry with claim cycle management
- Expertise is excel, power BI, data analytics
- Expertise in general industry trends.
- A thorough knowledge of the various types of insurance fraud and the strategies and techniques used in their investigation and of federal and state regulations
- Strong interpersonal/relationship skills.
- Excellent written and verbal communication skills used for interviewing and corresponding with claimants, attorneys, doctors, law enforcement, etc.
- A high degree of integrity, dependability, accountability and confidentiality is required for handling information that is considered personal and confidential.
- Ability to analyze data and interpret results.
- Ability to adapt, meet the changing demands of work environment, any delays or other unexpected demands.
- Ability to treat people with respect under all circumstances, instill trust in others besides upholding the values of organization.
- Ability collaborate and work with internal and external colleagues to successfully complete the defined tasks and provide superior customer service.
Desired candidate profile