Job Description
OVERALL PURPOSE:
Senior Specialist FWA Quality Control
– Reviewing and analyzing claims submitted to the Company to detect fraud, waste, and abuse with any deviation from accepted medical and insurance practice and confirming adherence of providers to all contract conditions through the Company’s system and field visits.
– Achieving reports about the quality and effectiveness of other departments.
Key Responsibilities:
1- Growth/Strategic Contribution
Senior Specialist FWA Quality Control
– Support the departmental strategies & play a vital role in maintaining the Quality of Medical management from the provider’s side by giving regular feedback on claims and treatment quality.
2- Financial Perspective
Senior Specialist – FWA Quality Control
– Analytical reporting for Medical utilization, treatment trends, & Management Patterns of providers showing upward diversion in Unit cost and frequencies.
3- Customer Experience
Senior Specialist FWA Quality Control
– Analyzing system operating capability in reference to department needs, reporting to management the requirement for better quality, and suggesting the requirement to improve quality and bring + impact on customer service.
4- Risk Perspective
– Assisting the team in identifying, the Fraudulent trend in providers’ billing and supporting the team in gathering evidence by Mystery shopping, file checking & member confirmation.
– Responsible for finalizing the fraud cases by sufficient evidence collection and achieving the assigned target in alignment with the reconciliation unit.
5- Policies, Systems, Processes & Procedures
– Assisting Team members to build guidelines and quality calculators for claims both medical & technical aspects.
– Assuring to achieve assigned targets particularly and departmental targets generally by close working with management.
– Periodically visit the providers for medical claims data verification, assisting the team during mystery shopping
7- Other
– Responsible for Health care providers profiling and focus billing trends of providers.
Academic Qualifications and Experience:
– Bachelor’s degree in Medicine
– 1 – 3 years of related experience
– English Proficiency
Skills
– Bachelor’s degree in Medicine
– 1 – 3 years of related experience
– English Proficiency
