Senior Medical Network Relations Officer

Walaa Cooperative Insurance Co.; Al Khobar; On-site; SAR 80,000 - 120,000; Full time

Job summary

An insurance company in Saudi Arabia seeks a professional specializing in Fraud, Waste, and Abuse prevention. The successful candidate will identify fraudulent claims, oversee compliance, and ensure financial integrity. They should possess a bachelor's degree and 3-5 years of relevant experience. Fluent Arabic is required, with English proficiency being an advantage. This role offers a unique opportunity to influence internal performance and policy measures in the organization.

Qualifications

• 3–5 years of hands-on experience in Fraud, Waste, and Abuse (FWA).
• 3–5 years in Reconciliation and Financial Oversight.
• 5+ years in Healthcare Insurance & Regulatory Compliance preferred.
• Understanding of regulatory and accreditation requirements.

Responsibilities

• Identify fraudulent claims and wasteful billing practices.
• Collaborate with legal teams and compliance officers.
• Review claims data to reconcile payments.
• Monitor provider compliance with agreements.

Skills

Integrity & Ethical Mindset

Attention to Detail

Analytical Thinking

Critical Thinking

Persistence & Patience

Communication Skills

Confidentiality & Discretion

Adaptability

Education

Bachelor's degree in finance or accounting

Healthcare Administration

Business Administration

Health Informatics

Tools

Power BI

Microsoft Office applications

Job description

Fraud, Waste, and Abuse (FWA) Prevention & Detection

• Identify fraudulent claims, wasteful billing practices, and abusive patterns using analytics and audits.
• Develop and implement anti-fraud policies, workflows, and compliance measures.
• Collaborate with legal teams, and compliance officers.
• Conduct provider and claims audits to validate services and detect irregularities.

Reconciliation & Recovery Management

• Review claims data to reconcile payments and provider contracts.
• Investigate discrepancies between billed, paid, and contracted rates.

Network Oversight & Compliance

• Monitor provider compliance with contractual agreements.
• Work with regulators to ensure legal compliance.
• Develop training programs for providers to reduce FWA risks.

Data Analytics & Reporting

• Use analytics tools (Power BI) to detect fraud trends.
• Generate FWA reports and provide actionable insights for executive leadership.
• Maintain dashboards tracking provider behavior, suspicious claims, and recovery metrics.

Stakeholder Collaboration

• Work with internal teams (claims, legal, provider relations, finance) to mitigate fraud risks.
• Partner with external entities (regulators, third-party auditors) to address fraud cases.
• Negotiate settlements & corrective action plans with providers involved in FWA.

Internal KPIs

These measure the company’s internal performance and effectiveness in detecting, managing, and preventing FWA, as well as ensuring the reconciliation process runs smoothly.

1. Fraud Detection Rate:

• Percentage of fraud cases detected vs. total fraud cases identified in the system.

1. Investigations Completed on Time:

• Percentage of fraud investigations that meet the predefined time frame for completion.

1. Case Resolution Time:

• Average time it takes to resolve FWA cases (from detection to resolution).

1. Recouped Amount:

• Total monetary value recovered from fraud, waste, or abuse incidents.

1. Employee Compliance:

• Percentage of employees adhering to internal fraud prevention and detection protocols.

1. Audit Effectiveness:

• Percentage of claims audited that result in identified issues (fraudulent, wasteful, or abusive practices).

1. Training Completion Rate:

• Percentage of relevant staff completing FWA prevention and detection training programs.

1. Reconciliation Accuracy:

• The percentage of claims and payments reconciled without discrepancies.

1. Rework Rate:

• Percentage of claims that require rework due to discrepancies in data or processes.

1. False Positive Rate:

• Percentage of flagged cases that are ultimately found to be non-fraudulent.

External KPIs

These focus on how the company performs in relation to external stakeholders, such as regulatory bodies, providers, and members.

1. Regulatory Compliance:

• The company’s adherence to legal and regulatory requirements for fraud detection and reconciliation processes.

1. Provider Compliance:

• Percentage of providers adhering to fraud prevention measures and ethical billing practices.

1. Member Satisfaction:

• Customer satisfaction scores related to claim disputes, fraud-related issues, and the claims reconciliation process.

1. Third-Party Audits:

• Results from audits conducted by external parties, including compliance checks and assessments of FWA detection systems.

1. Claim Denial Rate (due to FWA):

• Percentage of claims denied due to fraud, waste, or abuse detection.

1. Legal Actions/Settlements:

• Number of legal actions or settlements related to FWA, including lawsuits or settlements with external parties.

1. Reimbursement Recovery:

• Total amount recovered from external parties such as providers or members due to fraudulent claims.

1. External Stakeholder Feedback:

• Feedback from insurance agents, healthcare providers, or regulatory bodies about the effectiveness of the FWA prevention program.

Education

Bachelor’s degree in finance or accounting, Healthcare Administration, Business Administration or Health Informatics

Experience

• Hands-on experience in Fraud, Waste, and Abuse (3–5 years minimum)
• Reconciliation and Financial Oversight (3–5 years minimum)
• Healthcare Insurance & Regulatory Compliance (5+ years preferred)
• Understanding of regulatory and accreditation requirements related to provider networks.

Personal Attributes / Skills

1. Integrity & Ethical Mindset – Strong moral principles to handle sensitive financial and healthcare data responsibly.
2. Attention to Detail – Ability to spot anomalies, inconsistencies, and patterns in data.
3. Analytical Thinking – Logical approach to problem-solving and decision-making.
4. Critical Thinking – Evaluating evidence to determine fraud risks and compliance gaps.
5. Persistence & Patience – Fraud investigations and reconciliations can be complex and time-consuming.
6. Communication Skills – Clear reporting of findings to internal teams, auditors, and regulators.
7. Confidentiality & Discretion – Handling sensitive patient and financial information with care.
8. Adaptability – Keeping up with evolving fraud schemes and regulatory changes.

Others

• Fluency in Arabic language, working knowledge of the English language is an advantage.
• Proficiency in using Microsoft Office applications and database management.
• Ability to work independently and as part of a team to achieve network management goals.