Manager - Claims Integrity

Bupa Arabia


Date: 2 weeks 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:

  • 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.

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