Assistant Manager - Medical Quality Assurance, Fraud, Waste & Audit

métier - Strategic HR Solutions is hiring an – , , & for one of our leading insurance clients based in the GCC.

This role focuses on medical claims auditing, fraud detection, investigations, overpayment recovery, provider management, and risk mitigation within the medical insurance function.

• Conduct detailed audits of inpatient and outpatient medical claims to identify irregularities, fraud, waste, and abuse.
• Investigate suspicious claims and provide findings and recommendations for corrective action.
• Conduct retrospective reviews and support recovery of overpayments.
• Assess the appropriateness of treatments, medical coding, and billing practices.
• Analyze claims data to identify trends, risk indicators, and potential areas of abuse.
• Develop dashboards to monitor savings, fraud indicators, and audit performance.
• Collaborate with providers, claims, IT, and other stakeholders on fraud detection and risk controls.
• Support provider evaluation, credentialing, rate negotiations, and compliance reviews.
• Recommend appropriate action against non-compliant or abusive providers.
• Support the enhancement of policies, SOPs, audit standards, and digital fraud detection tools.

&

• MBBS, MD, BAMS, or equivalent medical qualification.
• Minimum 5 years of experience in medical insurance claims auditing and fraud detection.
• Proven experience in medical claims investigations and overpayment recovery.
• Certification in Fraud Detection, Health Insurance, Risk Management, or a related field is preferred.
• Strong knowledge of medical auditing, coding, treatment protocols, and claims processes.
• Willingness to relocate within the GCC.

• Medical Claims Audit & Quality Assurance
• Fraud, Waste & Abuse (FWA)
• Medical Claims Investigation
• Data Analysis & Reporting
• Provider Management
• Risk Mitigation & Compliance
• Strong stakeholder management and negotiation skills
• Advanced MS Excel proficiency