Claims Audit & Governance Senior Officer

MetLife Services and Solutions, LLC; Dubai; On-site; USD 70,000 - 100,000; Full time

Job summary

A leading company in the insurance sector is seeking a Claims Audit & Governance Senior Officer in Dubai. The role involves driving internal audits, analyzing claims data, and ensuring compliance with guidelines. Ideal candidates will have 5-10 years of experience in provider or payer organizations, with a strong focus on data analytics and fraud prevention.

Qualifications

• 5-10 years of experience with provider and/or payer organizations.
• Strong knowledge of billing patterns and coding.
• Proven success in data analytics and fraud pattern identification.

Responsibilities

• Perform regular reviews of medical claims data.
• Conduct claims audits of TPAs.
• Prepare claims samples and documentation for audits.

Skills

Data Analytics

Fraud Pattern Identification

Strategic Thinking

Partnership Building

Opportunity Seizure

Education

Graduate degree or MBA

Nursing, Pharmaceutical, or Medical degrees

Job description

Claims Audit & Governance Senior Officer

THE ROLE: Will be responsible for driving internal audits (claims & pre-approvals) and claims governance to ensure quality adherence to guidelines, meeting or exceeding quality standards, delivering timely audit results, and staying current with all applicable processes.

The specific duties include, but are not limited to:

1. Perform regular reviews of medical claims data to identify incorrect coding, waste, inaccuracies, overpayments, process gaps, leakages, and processing errors.
2. Review internal claims data to analyze performance and prevent incorrect coding, abuse, and fraudulent billing to control claims costs.
3. Conduct claims audits of TPAs to ensure effective claims controls and safeguard against operational risks.
4. Prepare claims samples and documentation for audits to verify proper coding, billing practices, and contractual compliance.
5. Maintain, communicate, and report audit results and findings within designated timelines.
6. Present audit findings and recommend improvements to management and stakeholders.
7. Conduct adjudicator performance reviews, provide feedback, and support scorecard completion.
8. Perform ad-hoc analyses and generate reports as needed.
9. Understand standard claim review processes and ensure alignment with policies, procedures, and business rules.
10. Maintain quality standards and meet audit and turnaround expectations.
11. Collaborate and communicate effectively across departments and stakeholders.
12. Ensure compliance with local regulatory requirements.

Reports to: Head of Medical Network and Vendor Management.

Direct Reports: None

CANDIDATE QUALIFICATIONS:

Business Knowledge/Technical Skills:

• 5-10 years of experience with provider and/or payer organizations, with strong knowledge of billing patterns and coding.
• Proven success in data analytics and fraud pattern identification within claims.
• Ability to develop creative solutions for medical quality management.
• Graduate degree, MBA, or advanced degree preferred.
• Nursing, Pharmaceutical, or Medical degrees are valuable but not mandatory.

Key Competencies:

• Strategic Thinking: Sets direction aligned with company strategy, applying controls to positively impact P&L.
• Partnership Building: Builds trusted relationships internally and externally, collaborating across teams to drive objectives.
• Opportunity Seizure: Identifies trends of provider abuse and explores new claims control methods.

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