Senior Medical Auditor - Fraud waste and Abuse
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Key skills for this role
About the Role
Dubai Insurance TPA is hiring a Senior Medical Auditor to conduct provider audits, analyze data, and manage DRG claims. Candidates need a nursing/paramedical degree, American medical coding certification, and 3-5 years of medical coding experience.
Key Skills for This Role
Responsibilities
- Conduct provider audits including data analysis, onsite visits, preparing audit reports, and presenting findings
- Prepare various reports related to audits (Quarterly, HICAL, Audit log, finance team reports, etc.)
- Case management of IP when referred
- Analyze and provide feedback on triggers raised for OP and reimbursement claims
- Handle queries from Operations teams on medical coding (DRG, unbundling, up coding, medical justification)
- Interact with other teams (Claim Centre, Network Team, IT) on medical coding and audits
- Report findings identified during audit that can affect or improve operations processes
- Flag or report providers identified with FWA activity
Requirements
- Bachelor's Degree (Nurse / Paramedical)
- American Medical Coding Education and certification
- 3 5 years of experience in medical coding within IP/OP and DRG claims
- Industry knowledge (healthcare / insurance)
- Analytical, attentive to details and assertive
- Excellent oral and written communication skills
- Computer literate
- Excellent command of the English language
Full Job Posting
Job Purpose
- The Auditor is responsible for external and internal audits and maintains the reports and processing DRG claims.
Responsibilities and Duties
- Conducting Provider audit: Data analysis, Onsite visits for audits, preparing audit reports based on the analysis and onsite visit, Presentation of the findings during audit meetings, Closure of audits as per the FWA team process.
- Preparation of various reports in relation to the audits (Quarterly, HICAL, Audit log, finance team reports etc)
- Case Management of IP when referred
- Analysis and Feedback on triggers raised for OP , reimbursement claims
- Handling / responding the queries of Operations team (Claims, Approvals, Reimbursement, Customer care, Network) on Medical Coding (DRG, unbundling code, up coding, medically justify) when required.
- Interacting with other Teams (Claim Centre, Network Team and IT) on Medical coding, audits, etc.
- Reporting of various findings identified during audit that can affect or improve the process of operations team.
- Flagging or reporting of providers identified with FWA activity.
Knowledge, Skills and Experience
- Bachelor’s Degree (Nurse / Paramedical)
- American Medical Coding Education and certification.
- Experience in medical coding of 3 5 years’ within IP/OP and DRG claims.
- Industry knowledge (healthcare / insurance).
- Should be analytical, attentive to details and assertive.
- Excellent oral and written communication skills.
- Must be computer literate.
- Excellent command of the English language.
Compensation
- Pay: From AED11,000.00 per month
Job Types
- Full time, Permanent
Work Location
- In person
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