Medical Provider Performance Executive
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Key skills for this role
About the Role
Nextcare seeks a Medical Provider Performance Executive to investigate healthcare fraud, waste, and abuse in Doha. The role involves data mining, audits, and provider relationship management.
Key Skills for This Role
Responsibilities
- Fraud Abuse and Waste detections and prevention from Medical providers for allocated regions/countries
- Data mining and data analysis are required for conducting investigations on provider claims
- Support and drive the savings target strategy as set by the Global head of MPM
- Review files, gather information, collect evidence to detect fraud and abuse on claims
- Document all evidence obtained in the investigation in order to substantiate meritorious claims, to deny unjustified claims, to recover inappropriate payments or to recommend action against responsible parties
- Participate in onsite Audits, in house claims audit and Mystery shopping campaigns
- Support the Medical Provider Performance Manager with all administration and support tasks to drive Fraud detections and prevention
- Assess the scope and determine the methodology needed to carry out an efficient investigation
- Prepare comprehensive investigative reports and analysis
- Collaborates and communicates internally with associated department’s ie legal, finance, claims operations as well as external clients and Providers
- Consults with legal and regulatory authorities for cases that may involve legal action
- Manages and ensures generation of periodic dashboards
Requirements
- Clinical knowledge – Medical or Para medical background
- Coding expertise – ICD, CPT, HCPCS proficiency
- Claims adjudication knowledge – Policies, benefits, exclusions, payer rules
- Fraud, Waste & Abuse (FWA) detection – Identifying anomalies, upcoding, unnecessary care
- Analytical skills – Data review, trend analysis, root cause identification
- Regulatory awareness – Compliance with local regulations, payer guidelines
- Attention to detail – Accuracy in audit reviews and documentation
- Audit methodology – Sampling, retrospective & concurrent audit techniques
- Negotiation and Communication skills – Clear reporting, provider engagement, negotiation and escalation handling
- Systems proficiency – Claims systems, audit tools, Excel/data tools
Full Job Posting
Job Overview
- This position is responsible for conducting objective, fair, thorough, unbiased and timely investigations of healthcare providers for fraud, waste and abuse committed against Allianz group or its Payers by members, providers, or other entities whist monitoring best of relationships with all parties.
- The position requires ingenuity and creativity to obtain case information not readily available, along with the ability to work independently with minimum supervision. Good organizational skills are needed to manage a high volume of assigned cases as well as the regular exercise of independent judgm
- The investigator must have the analytical ability necessary to review, interpret and evaluate relevant information essential in resolving sensitive and complex investigations.
Key Responsibilities
- Fraud Abuse and Waste detections and prevention from Medical providers for allocated regions/countries
- Data mining and data analysis are required for conducting investigations on provider claims.
- Support and drive the savings target strategy as set by the Global head of MPM
- Review files, gather information, collect evidence to detect fraud and abuse on claims
- Document all evidence obtained in the investigation in order to substantiate meritorious claims, to deny unjustified claims, to recover inappropriate payments or to recommend action against responsible parties
- Participate in onsite Audits, in house claims audit and Mystery shopping campaigns
- Support the Medical Provider Performance Manager with all administration and support tasks to drive Fraud detections and prevention.
- Assesses the scope and determine the methodology needed to carry out an efficient investigation.
- Prepare comprehensive investigative reports and analysis
- Collaborates and communicates internally with associated department’s ie legal, finance, claims operations as well as external clients and Providers.
- Consults with legal and regulatory authorities for cases that may involve legal action.
- Manages and ensures generation of periodic dashboards
Key Requirements
- Clinical knowledge – Medical or Para medical background
- Coding expertise – ICD, CPT, HCPCS proficiency
- Claims adjudication knowledge – Policies, benefits, exclusions, payer rules
- Fraud, Waste & Abuse (FWA) detection – Identifying anomalies, upcoding, unnecessary care
- Analytical skills – Data review, trend analysis, root cause identification
- Regulatory awareness – Compliance with local regulations, payer guidelines
- Attention to detail – Accuracy in audit reviews and documentation
- Audit methodology – Sampling, retrospective & concurrent audit techniques
- Negotiation and Communication skills – Clear reporting, provider engagement, negotiation and escalation handling
- Systems proficiency – Claims systems, audit tools, Excel/data tools
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