fraud-waste-abuse, contract case manager

Overview

Who you'll be working for

What requirements you'll need to be eligible

• Qualifications: Degree in Nursing or a healthcare-related discipline, or State Registered Nurse or Medical Assistant with 5 years of experience in post-basic and healthcare management.
• Working Experience: Minimum 5 years working experience in healthcare and/or insurance sector.
• Key Skills: Sound medical knowledge; knowledge of healthcare/medical billing and medical terminology; strong business acumen with communication, analytical, problem solving, documentation and organization skills; strong negotiation and public relation skills.

What you'll be doing on the job

• Review claims flagged out from POC/OCR project and identify claims with potential cost savings based on length of stay, claim amount, claim frequency, procedure charges, hospital charges, policy exclusion etc. and develop cost savings programme based on medical claim anomaly project findings.
• Work with Medical Claims and Network teams for findings related to hospitals/clinics on unusual or excessive bill charges.
• Work with Business Analytic team based on claim findings for improvement of medical claim anomaly detection model and make recommendations for improvement in detecting fraud, waste and abuse (FWA) during claim assessment.
• To actively take charge of fraud, waste and abuse (FWA) detection, initiate resolution and prevention to minimize wastages by reviewing and analyzing trends and emerging patterns in hospital and doctors’ charges, implementing controls on claims overutilization.

Consultant Contact