Manager - Claims Integrity
Bupa Arabia
Date: 2 weeks ago
City: Riyadh
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.
How to apply
To apply for this job you need to authorize on our website. If you don't have an account yet, please register.
Post a resumeSimilar jobs
Bartender (Dry)
The Ritz-Carlton Hotel Company, L.L.C.,
Riyadh
2 days ago
Additional InformationJob Number 26106925Job Category Food and Beverage & CulinaryLocation AlHada Area, Mekkah Road, Riyadh, Saudi Arabia, Saudi Arabia, 11493VIEW ON MAPSchedule Full TimeLocated Remotely? NPosition Type Non-ManagementPrepare drink orders for guests according to specified recipes using measuring systems. Set up and maintain cleanliness and condition of bar, bar unit, tables, and other tools. Prepare fresh garnishes for drinks. Stock...
Security Guard
PrimeGate for Communications and IT,
Riyadh
5 days ago
Responsibilities:Maintain the security and safety of the site.Monitor site entrances and exits.Check the identification of visitors and employees as required.Monitor the site and report any unusual incidents or observations.Follow security and safety procedures and instructions.Requirements:No criminal record.Commitment, discipline, and good conduct.Ability to perform the required security duties.Location: Riyadh, Saudi Arabia
Health Economics & Market Access (HEMA) Manager Middle East | Johnson & Johnson MedTech | UAE
Johnson & Johnson MedTech,
Riyadh
1 week ago
At Johnson & Johnson, we believe health is everything. Our strength in healthcare innovation empowers us to build a world where complex diseases are prevented, treated, and cured, where treatments are smarter and less invasive, and solutions are personal. Through our expertise in Innovative Medicine and MedTech, we are uniquely positioned to innovate across the full spectrum of healthcare solutions...
