Responsible for detecting Fraud, Waste and Abuse for AIA.
To conduct analysis with proper cost containment measures, recovery, and process improvements
To build guides, initiatives, and alignment of claims practices related to cost savings and quality claims processing
Medical Training and Medical Advisory within and beyond AHS
To ensure SOPS are updated periodically.
Job Responsibilities:
To ensure the Fraud tool is maintained and managed with care with insightful monthly analysis.
Well-versed with medical coding, 13th Schedule, MOH letters, reasonable and customary charges.
To conduct regular audits, and handle escalations to identify Fraud, Waste and Abuse.
To ensure claim adjudication is in accordance with reasonable and customary charges.
To review trending of doctors who may or may not be in the watch list.
To outline process improvement, cost saving measures, combating Fraud, Waste, and Abuse methods from audits.
To perform ad-hoc analysis to support medical advisory, agencies, corporate solutions, operations, network management, care management, product development and other relevant departments.
To build claim guides that collaborates with clinical guides and cost containment with effective implementation
To conduct robust medical training aligned with technical aspects of claims processing including training to hospitals.
To provide Medical Advisory including disputed charges, appeals and escalations.
To ensure projects related with audits/ analysis and cost savings are carried out within the stipulated timeline.
To actively engage and negotiate with stakeholders for recovery and remedial actions including watchlist and non-participating list of doctors / agents / hospitals / members.
To mentor/coach and guide the TLs and assessors in robust decision making.
To proactively identify and collaborate on the needful system enhancement and process automation.
Timely reporting and communication of all initiatives across all units in AIA.
Performs other responsibilities and duties periodically assigned by supervisor in order to meet operational and/or other requirements.
To participate and represent Medical Advisory, Case, and Fraud management in all necessary initiatives.
Job Requirements:
Medical doctor with clinical experience and preferably medical claims exposure.
Strong business acumen with strategic thinking ability to prognosticate factors that drive healthcare costs.
Good knowledge of current healthcare delivery systems and hospital billing systems.
Good stakeholder engagement skills (Specialists / internal teams).
Working experience in managed care organizations and insurance with familiarity with claims and analytic platforms (G400/CRM/MCS/LA/SAS/Tableau/Power BI/Microsoft Excel).
Proficiency in Insurance product knowledge and experience.
Well-versed with medical coding, 13th Schedule, MOH letters, reasonable and customary charges.
Dynamic with enthusiasm to lead with passion to provide seamless customer experience while ensuring compliance to insurance regulations.
Experience in Audit, Analysis, Fraud detection is an added advantage.
Good communication skills interacting with multi-level people to obtain information / build and nurture relationships / dispute resolution related to claims / billing
Good communication skills managing specialists, medical directors, MDAC etc. in a non-confrontational manner
