Detective Leader

The Lead Claims Detective is responsible for leading the claims detection, fraud prevention and abuse initiatives across the Middle East and Africa region.

This role will be accountable for the success of the unit in multiple cost containment, quality management and payment integrity initiatives.

• Claims Detection:
  • Monitor and review claims audits to identify fraud and abuse trends and ensure objectives are met in a timely and efficient manner.
  • Review pending lists of scheduled providers/incidents on a regular basis and ensure targets are fully met and in line with fraud management and detection TAT.
  • Follow up on progress in coordination with respective providers for complicated fraud and abuse incidents.
  • Conduct periodic quality assurance on assigned audits and recoveries to ensure compliance with applicable regulations and accuracy of information.
  • Report FWA to regulatory bodies.
• Team Management Support:
  • Supervise and manage the performance of direct reports, defining targets and work schedules, and guiding them on expected levels of achievement.
  • Conduct regular audits and random checks to ensure delivery timelines are met as per operational targets and reduce/eliminate margin of errors during processes.

• Prepare weekly/monthly/quarterly/annual business reports related to sampled data, positive findings and recovery process.
• Prepare regulatory reports for FWA as per pre-defined regulatory framework.
• Prepare payer reports for FWA and Utilization.
• Review and sign off full audit reports prior to closure of audits.