Manager Claims Integrity

About the Role

Bupa Arabia is seeking a Manager Claims Integrity to join their team in Riyadh, Saudi Arabia. This full-time role involves performing detailed reviews and analyses of cases related to fraud, waste, and abuse (FWA), claims patterns, and emerging market trends. The primary objective is to ensure accurate assessment, thorough evidence documentation, informed decision support, effective recovery follow-up, and continuous feedback for claims integrity controls and process improvements.

Key Responsibilities

• Conduct detailed reviews of FWA-related cases, alerts, claims patterns, and suspicious provider/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 processes.
• Arrange collected data and evidence for negotiation and decision-making regarding fraudulent cases.
• Discuss evidence with the Provider Relations Team for substantiation and negotiate for recoveries that align with target forecasts.
• Complete necessary reports and files for escalation to regulatory bodies.
• 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.
• 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 improvement.

Experience and Qualifications

Candidates for this role should possess 0-1 years of relevant experience. The position requires a professional who can conduct thorough analysis and maintain meticulous documentation.

Work Environment

This is a full-time position based in Riyadh, Riyadh, Saudi Arabia, within the Bupa Arabia team.

Application Process

Interested candidates are encouraged to apply. Salary details will be disclosed during the interview process.