Officer, Member Investigation (UAEN)

Role Purpose

Serve as the primary interface of the department to investigate suspected member fraud cases and draft relevant reports for internal and external stakeholders

Review system(s) reports and summarise key information related to departmental significant activities and perform data analysis for on-going identification of process/metrics improvement opportunities

Liaise with internal and external stakeholders to have an up-to-date information on the member fraud investigation relevant rules and guidelines

Develop a mechanism to keep track of all escalated cases from internal and external stakeholders and provide status update

Participate in the Member Fraud planning and organising of activities

Participate and support in Medical Audit/Investigation assignments as required

Support the Investigation team in exporting, analysing data to understand the members utilisation behaviour, identify any fraud and abuse behaviour findings, recommend effective methods or measures for addressing and closing the gaps

Deliver high quality customer service and respect medical and work ethics at all times

Ensure that business decisions and processes are documented in a professional way and the communication requirements are being adhered to in a timely and professional manner

Support the Director in ensuring the development, implementation and proper adherence of departmental policies and procedures

Key Requirements and Qualifications

Minimum 2 years of relevant experience in audit, investigation, data analysis or similar job

Bachelor's degree in any discipline

Certified Fraud Examiner qualification is an advantage

Skills and Competencies

Sound understanding of health insurance law and compliance regulations

Knowledge of the regulatory standards pertaining to applying for insurance and enrolment details in the Emirate of Abu Dhabi and the U.A.E.

Knowledge of Daman's overall processes, systems, tools and relevant defined data attributes and interfaces with internal and external stakeholders

Billing record auditing skills for pharma claims

Knowledge of health insurance's claims billing and payment common errors, fraud and abuse behaviour

Good project management skills

Very good command of written and spoken English & Arabic language

Strong level of business understanding and background