As a Medical Fraud Analyst within the Payment Integrity FWA Team, you will be directly supporting the company's affordability commitment within the company's International business in Riyadh, Saudi Arabia. This role is responsible for detecting and recovering FWA payments for non-network claims, creating solutions to prevent claims overpayment, and monitoring future spending within a dedicated region. You will collaborate closely with various teams including Network, Medical Economics, Data Analytics, Claims Operations, Clinical partners, Product, and the International Member Investigation Unit (MIU).
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What You’ll Do
- Identify and investigate potential instances of medical fraud, waste, or abuse (FWA) or error across the company's International Markets for claims incurred in KSA.
- Perform a variety of prepay focused cost avoidance activities.
- Seek recovery of FWA payments from claim submissions.
- Ensure PI savings are tracked and reported accurately.
- Partner to implement solutions and drive execution to prevent claims overpayment and unnecessary claim spends while ensuring the timeliness and accuracy of the PI claims review process.
- Negotiate with out-of-Network providers.
- Utilize data mining to reveal FWA trends and patterns.
- Partner with the company's TPAs on FWA investigations.
- Collaborate with Payment Integrity teams in other locations to share FWA claiming schemes.
- Work with the Data Analytics team to build future FWA triggers automation.
- Provide investigation reports to internal and external stakeholders.
- Comply with local regulations including data residency restrictions.
- Collaborate with the Compliance team on subrogation for local claims in KSA as needed.
What You’ll Bring
- An enjoyment of working in a high-performance team that holds each other accountable.
- Experience in investigation within payment integrity or a related field.
- 3-5 years of experience in health insurance or healthcare provider settings.
- Knowledge of claims coding, local regulatory rules, and medical policy; medical/paramedical qualifications are a plus.
Skills
- A critical mindset with the ability to identify cost containment opportunities.
- Experience with data analytics.
- Strong organizational skills and attention to detail.
- The ability to quickly learn new and complex tasks and concepts.
- Excellent verbal and written communication skills.
- Capability to manage multiple priorities and meet tight deadlines.
- Flexibility to work with global teams across varying time zones.
- Strong interpersonal skills to liaise with internal stakeholders while working independently within a cross-functional team.
- Fluency in Arabic and English is essential.
