At AIA we've started an exciting movement to create a healthier, more sustainable future for everyone.
Sound like you Then read on.
About the Role
. 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.
. To support TDA/Squads and other projects as required
- 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.
Minimum Job Requirements:
Degree in Health or Life Sciences, Allied Health or relevant disciplines
Working experience in healthcare or managed care or insurance industry.
Knowledge in healthcare management, experience in nursing and medical advancement.
Good verbal and written communication skills, problem solving skills, able to manage people, fundamental knowledge in accounting principles, good analytical skills, proficiency in basic computer operating software like MS Office, willing to travel for job assignments.
