Manager Claims Integrity📣 إعلان

About the Role

Bupa Arabia is seeking a Manager - Claims Integrity to join its team in Al Khobar. This full-time position is central to upholding the integrity of claims processes and ensuring financial accuracy within the organization.

Role Purpose and Impact

The primary objective of this role is to conduct detailed reviews and analyses of cases related to fraud, waste, and abuse (FWA). This includes examining alerts, claims patterns, and emerging market trends to facilitate accurate assessments, thorough evidence documentation, and informed decision-making. The Manager will also support recovery efforts and contribute feedback for continuous improvement of Claims Integrity controls and processes.

Key Responsibilities

• Review FWA-related cases, alerts, claims patterns, and suspicious provider or member behaviors.
• 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.
• Analyze repeated claims behaviors, provider trends, market practices, and emerging FWA patterns.
• Identify new or evolving abuse behaviors that may necessitate new controls, rules, reviews, or process changes.
• Provide observations and feedback to support the enhancement of Claims Integrity controls and detection logic.

Negotiation and Recovery Support

• Organize collected data and evidence to facilitate negotiation and decision-making processes.
• Discuss evidence with the Provider Relations Team for substantiation.
• Negotiate with the Provider Relations Team to achieve targeted recovery outcomes.
• Complete necessary reports and prepare files for escalation to regulatory bodies.
• 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 opportunities for process improvement.

Required Experience

Candidates for this position should possess 2 to 5 years of relevant professional experience in claims integrity, fraud detection, or a related analytical role within the insurance or healthcare sector.

Work Location

This is a full-time role based in Al Khobar.