Job Description

Qualification required: Masters and Bachelor in Medical field


Experience required : 8-10 years of In the Medical field ( medical auditing )


Nationality: Preferably Emirati, but other nationalities are not objectionable

Main Task:

1. Review all allegations of potential Fraud, Waste and Abuse (FWA).


2. Provides recommendations to close inquire or open investigative cases in order to prevent and detect health insurance Fraud, Waste and Abuse (FWA).


3. Prepare the annual audit plan pertaining to the facilities that will be audited in the current year.


4. Make data analysis, research and review of claims data to identify trends, patterns and emerging issues in healthcare fraud, waste and abuse. All to ensure consistency and completeness.


5. Make recommendation on the CPT coding rules for the FWA Tool to create a list of the rules in the tool for easy and early detection.


6. Ensure the accuracy and compliance of diagnosis codes, given services & treatments and all medical billing documentation as per regulatory standards.


7. Participate and conduct onsite audit visit (once recommended) to investigate of fraudulent, wasteful and abusive activities at healthcare providers and other health insurance parties.


8. Review contract terms, medical records, claims history, financial records and other documentation to determine FWA and identify potential patterns.


9. Write clear, concise reports about the audit findings; submit it to the line manager.


10. Maintain all documentation for Fraud, Waste and Abuse (FWA) cases and update the tracker regularly.


11. Follow up with TPA regarding the settlement of recoverable amount or payment plan agreements and track it.


12. Communicate with members and parties involved in health insurance related activities routinely regarding issues including investigative findings, recoveries, and educational feedback where appropriate.


13. Maintain Confidentiality of the Insurance corporation internal process, information, violations, any findings, stakeholders, documents, plans, ...... etc.


14. Review, interpret and apply the health insurance law with its decrees in detecting the violations for healthcare providers.


15. Ensure reporting for all details and evidences in the post-audit report to be inclusive of the finding's summary and suggestions for any corrective actions.


16. Share knowledge, educate staff and conduct training or workshops once recommended.


17. Perform any other duties as assigned by the department's director based on the authority channel dealt with officially in the Insurance Corporation in the organization.