Manager - Claims Integrity
Bupa Arabia
Date: 8 hours ago
City: Al Khobar
Contract type: Full time
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:
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.
- 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
- 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.
- 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.
- 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.
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