FWA Officer

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

Lead the oversight of FWA detection and prevention processes , including governance of tools, rules, and investigation frameworks

Drive timely escalation, investigation, and closure of suspected FWA cases , in coordination with relevant stakeholders including TPA.

Continuously enhance FWA controls, analytics, and reporting frameworks in conjunction with TPA governance.

TPA Governance & Performance Management

Act as a central governance point for TPA operations , ensuring adherence to SLAs, KPIs, and contractual requirements

Monitor and assess TPA claims adjudication quality, accuracy, and consistency

Conduct periodic governance reviews and performance assessments of TPAs

Provider Network Performance Oversight

Oversee provider performance and billing behavior through TPA data and insights

Perform network provider onsite & offsite audits

Support implementation of corrective actions, cost containment strategies, and provider engagement initiatives

Stakeholder Management & Collaboration

Collaborate with TPAs, provider networks, internal teams (Claims, Medical, Compliance, Finance), and external stakeholders

Present insights, findings, and recommendations to management and cross-functional teams

Support training, feedback, and capability building initiatives across TPAs

Reports to : Head of Managed Care Services

Direct Reports : NA

Desired Candidate Profile

Business Knowledge/Technical Skills:

3 - 5 years of experience with provider and / or payer to have a strong knowledge of billing patterns and coding

Strong record of success in data analytics and identification of fraud patterns within claims.

Possess skills to develop creative solutions for medical quality management

A graduate degree, MBA degree or other advance degree is preferred

A nursing degree or Pharmaceutical or Medical degree will be of value however not mandatory.