Assistant Manager - Medical Quality Assurance, Fraud, Waste & Audit

métier - Strategic HR Solutions is hiring an 𝐀𝐬𝐬𝐢𝐬𝐭𝐚𝐧𝐭 𝐌𝐚𝐧𝐚𝐠𝐞𝐫 – 𝐌𝐞𝐝𝐢𝐜𝐚𝐥 𝐐𝐮𝐚𝐥𝐢𝐭𝐲 𝐀𝐬𝐬𝐮𝐫𝐚𝐧𝐜𝐞, 𝐅𝐫𝐚𝐮𝐝, 𝐖𝐚𝐬𝐭𝐞 & 𝐀𝐮𝐝𝐢𝐭 for one of our leading insurance clients based in the GCC.
This role focuses on medical claims auditing, fraud detection, investigations, overpayment recovery, provider management, and risk mitigation within the medical insurance function.
𝐊𝐞𝐲 𝐑𝐞𝐬𝐩𝐨𝐧𝐬𝐢𝐛𝐢𝐥𝐢𝐭𝐢𝐞𝐬
Conduct detailed audits of inpatient and outpatient medical claims to identify irregularities, fraud, waste, and abuse.
Investigate suspicious claims and provide findings and recommendations for corrective action.
Conduct retrospective reviews and support recovery of overpayments.
Assess the appropriateness of treatments, medical coding, and billing practices.
Analyze claims data to identify trends, risk indicators, and potential areas of abuse.
Develop dashboards to monitor savings, fraud indicators, and audit performance.
Collaborate with providers, claims, IT, and other stakeholders on fraud detection and risk controls.
Support provider evaluation, credentialing, rate negotiations, and compliance reviews.
Recommend appropriate action against non-compliant or abusive providers.
Support the enhancement of policies, SOPs, audit standards, and digital fraud detection tools.
𝐐𝐮𝐚𝐥𝐢𝐟𝐢𝐜𝐚𝐭𝐢𝐨𝐧𝐬 & 𝐄𝐱𝐩𝐞𝐫𝐢𝐞𝐧𝐜𝐞
MBBS, MD, BAMS, or equivalent medical qualification.
Minimum 5 years of experience in medical insurance claims auditing and fraud detection.
Proven experience in medical claims investigations and overpayment recovery.
Certification in Fraud Detection, Health Insurance, Risk Management, or a related field is preferred.
Strong knowledge of medical auditing, coding, treatment protocols, and claims processes.
Willingness to relocate within the GCC.
𝐊𝐞𝐲 𝐒𝐤𝐢𝐥𝐥𝐬
Medical Claims Audit & Quality Assurance
Fraud, Waste & Abuse (FWA)
Medical Claims Investigation
Data Analysis & Reporting
Provider Management
Risk Mitigation & Compliance
Strong stakeholder management and negotiation skills
Advanced MS Excel proficiency

Work arrangement
No