Manager - Claims Integrity

Bupa Arabia


Date: 6 hours 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:

  • 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.

Negotiating the fraudulent cases:

  • 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

Market Trend & Behaviour Identification:

  • 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.

Recovery Support & Process Improvement Feedback:

  • 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.

Skills

  • 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 resume

Similar jobs

Incident Manager (Arabic speaker)

Motorola Solutions, Riyadh
4 hours ago
Company OverviewAt Motorola Solutions, we believe that everything starts with our people. We’re a global close-knit community, united by the relentless pursuit to help keep people safer everywhere. We build and connect technologies to help protect people, property and places. Our solutions foster the collaboration that’s critical for safer communities, safer schools, safer hospitals, safer businesses, and ultimately, safer nations....

Talent Acquisition Specialist

UNECO MEP, Riyadh
1 day ago
As an employee of our company, you will collaborate with each department to create and deploy disruptive products. Come work at a growing company that offers great benefits with opportunities to moving forward and learn alongside accomplished leaders. We're seeking an experienced and outstanding member of staff.This position is both creative and rigorous by nature you need to think outside...

Production Lab and Glaze Manager | EXA Ceramics

alfanar, Riyadh
3 days ago
Job description: Job Purpose To lead and manage the Production Laboratory and Glaze Preparation sections by ensuring consistent quality, process efficiency, and production innovation through raw material testing, glaze formulation, process optimization, and team development to meet production targets and quality standards. Key Accountability Areas Laboratory Management Supervise lab activities including raw material analysis, chemical testing, and quality issue correction...