Job Description
OVERALL PURPOSE:
Senior Specialist – Roving Doctor
– To manage the assessment and investigation of medical claims by visiting assigned medical providers to identify potential fraud or abuse cases and accordingly develop and implement preventive/corrective actions. Negotiate cases with doctors to provide the best services for clients.
Key Responsibilities:
1- Strategic Contribution:
Senior Specialist – Roving Doctor
– Contribute to the implementation and execution of the division’s short to mid-term plans by monitoring compliance, identifying, and addressing fraud or abuse cases.
– Report key findings related to fraud and abuse cases for inpatient cases and recommend corrective actions to the management.
2- Operational:
Senior Specialist – Roving Doctor
– Conduct daily visits to medical providers to investigate and audit inpatient cases and ensure the best service is provided to clients in a cost-efficient way.
– Provide approvals on compliant patient services as required and in alignment with policies and procedures.
– Negotiate and assess inpatient cases with the service providers on site (hospital, clinics, etc..) with regards to treatments, medical, procedures, medication, etc. to ensure clients receive the best service and optimize the average cost per claim.
– Ensure that the medical service provider members in the designated network of providers are up to standard, qualified, and in compliance with ART’s policies and procedures.
– Ensure the development of preventive/ corrective actions, processes, es and procedures in response to incidents investigated and monitor implementation.
– Assist in analyzing fraud and abuse incidents in order to prevent them from reoccurring and support the management’s inadequate decision-making.
– Contribute to the delivery of fraud detection training and awareness campaigns in order to strengthen capabilities within ART.
– Conduct investigations and audits on medical records as needed with medical providers in order to address any malpractice, misconduct, and fraudulent activity, provide recommendation measures, and be in compliance with ART’s policies and procedures.
– Contribute to building sustainable relationships with key stakeholders across medical providers by demonstrating strong communication skills.
– Resolve any escalated issues rapidly and efficiently.
Senior Specialist – Roving Doctor
3- Policies, Systems, Processes & Procedures:
Senior Specialist – Roving Doctor
– Follow all relevant departmental policies, processes, standard operating procedures, and instructions to ensure work is carried out in a controlled and consistent manner.
4- Continuous Improvement:
– Contribute to the identification of opportunities for continuous improvement of processes, productivity, and cost reduction related to own work.
5- Reporting:
– Ensure that all relevant periodic and ad-hoc reports are prepared timely and accurately, and meet the function’s requirements, policies, and standards.
6- CyberSecurity
– Responsible for complying with cyber security policy, standards, and procedures
Academic Qualifications and Experience:
– Bachelor’s degree in medicine or Doctor of Medicine or other relevant fields
– 4+ years of experience in the insurance field
– English Proficiency
Skills
– Bachelor’s degree in medicine or Doctor of Medicine or other relevant fields
– 4+ years of experience in the insurance field
– English Proficiency
