Manager Claims Integrity📣 إعلان

About Bupa Arabia and the Role

Bupa Arabia is seeking a Manager Claims Integrity to join their team in Al Khobar, Eastern region. This full-time position is designed for professionals with 0-1 years of experience who are dedicated to upholding the integrity of claims processes. The role is central to identifying and mitigating risks associated with Fraud, Waste, and Abuse (FWA) within the healthcare insurance sector.

Role Overview

The primary purpose of this role is to conduct detailed reviews and analyses of FWA-related cases, alerts, claims patterns, and emerging market trends. The Manager Claims Integrity ensures accurate assessment, meticulous evidence documentation, and provides crucial decision support. This position also plays a key part in recovery follow-up and feeding insights back into continuous improvement initiatives for Claims Integrity controls and processes.

Key Responsibilities

• Perform detailed reviews of 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 all findings clearly to support decisions, facilitate recoveries, enable escalations, or prompt further review.
• Prepare and arrange collected data and evidence for negotiation and decision-making processes.
• Discuss evidence with the Providers Relation Team to substantiate findings and negotiate for required recoveries that align with target forecasting.
• Complete necessary reports and prepare files for escalation to regulatory bodies when required.
• Analyze repeated claims behaviors, provider trends, market practices, and emerging FWA patterns to identify new or evolving abuse behaviors.
• Provide observations and feedback to support the 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 that review outcomes are actioned appropriately and provide feedback on operational gaps, false positives, and improvement opportunities.

Experience Required

This position requires 0-1 years of experience, making it suitable for individuals at the entry level of their professional career who are eager to develop expertise in claims integrity and FWA analysis.

Work Type and Location

This is a full-time role based in Al Khobar, located in the Eastern region of Saudi Arabia. The successful candidate will work within a dedicated team focused on maintaining high standards of claims integrity.

Application

Candidates interested in contributing to the robust claims integrity framework of Bupa Arabia are encouraged to apply.