Medical Specialist, Quality Audit & Controls ( doctor)

Daman - National Health Insurance Company; Abu Dhabi; On-site; AED 120,000 - 200,000; Full time

Job summary

A leading national health insurance company seeks a Claims Auditor with a Bachelor's degree in Medicine and 3–5 years of experience to oversee quality audits, enhance compliance, and support claims processing efficiency. Join us to drive operational excellence while ensuring adherence to industry standards and best practices.

Qualifications

• 3–5 years of experience in healthcare insurance claims audit and controls.
• Previous exposure to quality audits and compliance processes.
• Strong understanding of claims processing.

Responsibilities

• Execute quality audits and control activities for claims processing.
• Track and report on KPIs related to claims accuracy.
• Support the implementation of automated audit tools.

Skills

Quality Auditing

Fraud Detection

Compliance Monitoring

Claims Processing

Documentation

Education

Bachelor’s degree in Medicine

CPCU, AICPCU, CHC, LOMA certifications

Job description

Core Responsibilities

• Execute quality audits and control activities for claims processing.
• Support the implementation of automated audit tools to improve efficiency and accuracy.
• Assist in fraud detection and prevention efforts to protect financial integrity.
• Track and report on key performance indicators (KPIs) related to claims accuracy, error rates, and audit outcomes.
• Follow standardized review processes to ensure consistency in claims quality assessments.
• Coordinate with the claims team to address discrepancies and support quality improvements.
• Ensure compliance with medical coding, billing regulations, and internal policies.
• Contribute to fostering a culture of quality assurance and continuous improvement.
• Prepare and share audit findings and insights with senior team members to support decisions.
• Help enhance claims quality assessment methods by applying best practices.
• Maintain accurate documentation of audit procedures and results.
• Support risk management by identifying potential issues in claims processing.

Quality & Excellence Management

• Monitor claims processing trends to help identify areas for quality improvement.
• Assist in enhancing compliance monitoring processes.
• Support initiatives aimed at reducing claims errors and improving efficiency.
• Apply audit control best practices to help achieve operational excellence.
• Provide input on technological solutions that may improve auditing processes.
• Promote high standards in audit and control work.

Preferred Educational Qualifications and Professional Certifications

• Bachelor’s degree in Medicine (mandatory)
• Professional certifications such as CPCU, AICPCU, CHC, LOMA certifications, or equivalent are an advantage.

Experience

• 3–5 years of experience in healthcare insurance claims audit and controls.
• Previous exposure to quality audits, compliance processes, and claims processing is preferred.