FWA Detection & Governance Lead

Gender; Oman; On-site; OMR 18,000 - 24,000; Full time

Job summary

Gender Oman seeks a skilled professional to lead oversight of FWA detection and prevention, govern tools, rules, and investigation frameworks. You will drive timely escalation, investigation, and closure of suspected FWA cases in coordination with TPAs and relevant stakeholders.

You will continuously enhance FWA controls, analytics, and reporting in line with TPA governance. Additional duties include governance of SLAs and KPIs, provider performance oversight, audits, and collaboration with

Qualifications

• 3–5 years of provider/payer experience with billing patterns and coding.
• Strong data analytics experience and fraud pattern identification in claims.
• Ability to develop creative solutions for medical quality management.
• Graduate degree such as MBA preferred; clinical degrees valued but not mandatory.

Responsibilities

• Lead oversight of FWA detection and prevention, governance of tools, rules and investigation frameworks.
• Escalate, investigate, and close suspected FWA cases with stakeholders including TPA.
• Enhance FWA controls, analytics, and reporting with TPA governance.
• Govern TPA operations through SLAs, KPIs and contractual requirements.
• Monitor TPA claims adjudication quality and consistency.
• Conduct governance reviews and performance assessments of TPAs.
• Oversee provider performance and billing behavior via TPA data.
• Perform provider audits onsite and offsite; support corrective actions and cost containment.
• Collaborate with TPAs, provider networks, internal teams and external stakeholders.
• Present insights and recommendations to management; support training and capability building across TPAs.

Skills

Data analytics

Fraud pattern detection

Billing & coding knowledge

Stakeholder collaboration

Education

MBA or graduate degree

Nursing/Pharmacy/Medical background (optional)

Job description

Gender Oman seeks a skilled professional to lead oversight of FWA detection and prevention, govern tools, rules, and investigation frameworks. You will drive timely escalation, investigation, and closure of suspected FWA cases in coordination with TPAs and relevant stakeholders.

You will continuously enhance FWA controls, analytics, and reporting in line with TPA governance. Additional duties include governance of SLAs and KPIs, provider performance oversight, audits, and collaboration with