Manager Claims Integrity📣 Job Ad

About Bupa Arabia and the Role

Bupa Arabia is seeking a Manager - Claims Integrity to join our team in Al Khobar. This is a full-time position focused on upholding the integrity of our claims processes. The role involves critical analysis and strategic action to address fraud, waste, and abuse within the claims landscape.

Role Overview

The Manager - Claims Integrity is responsible for performing detailed reviews and analyses of FWA-related cases, alerts, claims patterns, and emerging market trends. This role ensures accurate assessment, thorough evidence documentation, and provides decision support for recovery efforts. A key aspect is providing feedback to enhance Claims Integrity controls and process improvement initiatives.

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 processes.
• Coordinate with relevant stakeholders to ensure that review outcomes are actioned appropriately.

FWA Case Management and Recovery

• Arrange collected data and evidence to facilitate negotiation and decision-making processes.
• Discuss evidences with the Providers Relation Team for substantiation and validation.
• Negotiate with the Provider Relation Team to achieve necessary recoveries that align with target forecasts.
• Complete all required reports and prepare files for escalation to regulatory bodies when necessary.
• Support recovery follow-up by providing validated findings, evidence, and clear business rationale.

Market Trend Analysis and Integrity Enhancement

• Analyze repeated claims behaviors, provider trends, market practices, and emerging FWA patterns.
• Identify new or evolving abuse behaviors that may necessitate the implementation of new controls, rules, reviews, or process adjustments.
• Provide observations and feedback to support the continuous enhancement of Claims Integrity controls and detection logic.
• Offer 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 analysis, or a related field.