Claims Auditor

This position is primarily responsible for managing Direct Billing Claims , overseeing Fraud, Waste, and Abuse (FWA) controls , and ensuring accurate Reconciliation Management .

Core Responsibilities

• Direct Billing Claims Management : Conduct audits, perform detailed analysis, and ensure compliance.
• Fraud, Waste, and Abuse Oversight : Identify irregularities, analyze patterns, lead investigations, and implement control measures.
• Reconciliation Management : Coordinate with TPAs and Finance teams to ensure accurate reconciliations.
• TPA Performance Evaluation : Monitor and assess Third-Party Administrators’ performance.
• Claims System Testing & Development : Support system enhancements and functionality testing.
• Medical Assessment : Review and validate medical claims and documentation.
• KPI Compliance : Ensure timely achievement of key performance indicators.
• Process Improvement : Drive innovation and implement process enhancements.

Qualifications & Requirements

• Education : MBBS or MD degree (Medical Doctor).
• Skills :
• Strong interpersonal and communication skills (Arabic & English – written and verbal).
• Proficiency in MS Excel and Word.
• Other Requirements :
• Valid driving license (frequent travel to network providers and TPAs for audits and reconciliations).