Specialist, Medical Audit ( UAEN with medical coding knowledge)

Core Responsibilities:

• Conduct detailed audits of home care, LTC, and dental claims to assess their validity, appropriateness, and compliance.

• Monitor patterns of utilization and identify cases of overuse, underuse, or misuse of healthcare services.

• Draft comprehensive audit reports, summarizing findings, identified risks, and recommended corrective actions.

• Implement preventive measures and process improvements to minimize financial losses due to fraudulent or unnecessary claims.

• Liaise with healthcare providers to verify claim-related concerns and request supporting documentation when required.

• Participate in case reviews and assist in claim adjudication processes based on audit findings.

• Coordinate with medical and legal teams to support investigations and dispute resolution cases.

• Adapt audit techniques and strategies based on new developments in home care, LTC, and dental healthcare services.

• Provide technical input in policy enhancements related to claims processing, billing guidelines, and audit requirements.

• Receive and review complaints regarding questionable medical claims and investigate their validity.

• Conduct on-site provider audits, ensuring adherence to quality and regulatory standards.

Quality & Excellence Management:

• Monitor adherence to local and international healthcare regulations in medical audit processes.

• Develop and implement quality assurance measures to enhance the accuracy and reliability of audits.

• Coordinate with quality management teams to improve service delivery and provider compliance.

• Implement standardized procedures for documentation and record-keeping in medical audits.

• Contribute to the continuous improvement of audit workflows and methodologies.

Preferred Educational Qualifications and Professional Certifications

• Bachelor's Degree in Medicine, Dentistry, Pharmacy, Nursing, Physiotherapy, Healthcare Management, or a related field.

• Master's Degree in Healthcare Management, Public Health (MPH), Business Administration (MBA - Healthcare Focus), or Insurance & Risk Management, or a related field is preferred.

• Professional certifications such as Certified Healthcare Auditor (CHA), Certified Fraud Examiner (CFE), Certified Professional in Healthcare Quality (CPHQ), or equivalent is advantageous.

Experience

• A minimum of 2-4 years of experience in medical auditing, claims review, fraud detection, or healthcare risk management within the insurance or healthcare industry.