Manager - Claims Integrity
Bupa Arabia
Date: 4 hours ago
City: Remote
Contract type: Full time
Remote
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
Tamayyaz – Reservation Agent – Saudis Only
ibis, ibis Styles, ibis budget,
Remote
3 days ago
Company Description“Tamayyaz is a Nationalization Development Program that enables Saudi talents to acquire the needed skills & knowledge for various professions within the hospitality field within a specific time frame by using a combination of classroom learning and On Job Training.”Job DescriptionPRIMARY OBJECTIVE OF POSITIONTo maximize hotel revenue and guest satisfaction by receiving, handling and processing guest reservations under the...
Human Resource Specialist | Remote
Re Lytics Hires,
Remote
3 days ago
This opportunity is ideal for a people-focused professional who enjoys supporting employee-related processes, maintaining accurate records, and contributing to positive workplace experiences. The Human Resource Specialist will assist with essential HR activities while ensuring information is organised, confidential, and handled professionally. The successful candidate will support recruitment coordination, employee documentation, HR administration, and internal communication activities. You will work remotely...
Project Planning & Control Manager
Dan - PIF Company,
Remote
3 days ago
We're Hiring | Project Planning & Control ManagerWe are looking for an experienced Project Planning & Control Manager to join our Development Control team and play a key role in delivering large-scale development projects.This position is ideal for professionals with strong Owner-side or PMC experience in project planning, controls, scheduling, budgeting, and performance reporting across complex, multi-project environments.Key Responsibilities:Lead the...
