This role is about supporting the department in detecting and eliminating FWA in the health insurance system. The officer will be responsible to identify FWA via analysis of provider claims data billing patterns for abnormal behaviours that require audit/investigation, that would benefit our cost optimization processes.
- Develop and execute simple to complex SQL scripts to gather data.
- Analyse the gathered data to identify and articulate to the requester the trends and irregularities demonstrated in the data.
- Develop and share reports, presentations, and data to the end user for actionable and targeted audits.
- Develop and implement new system advancements to enhance the audit accuracy and operational efficiency e.g., sampling scripts, reporting tools.
- Compile and analyse audit related data and prepare and maintain an audit repository.
- Define and document audit logic for end-users to follow and after translation into SQL language.
- Participate in the audit planning and organizing of audit activities.
- Collaboration with internal/external stakeholders on cost containment initiatives
- Provide periodic strategic audit analysis reports.
- Ability to read and understand statistical analysis of provider behaviour.
- Provide input to new strategic audit initiatives and new audit developments on request and will be expected to successfully lead medium to complex projects.
- Maintain up-to-date knowledge about audit tools and techniques.
- Minimum 4 years of experience in the healthcare industry
- Minimum 1 year experience in a similar role
- Sound understating of local market and health insurance law, compliance, and regulations
- Bachelor's degree in business, Data, Computer Science/programming, Statistics/Mathematics or similar degree is required
- Knowledge of Medical Coding and reimbursement highly desired
