•Conduct data driven on-site audits of healthcare service providers, checking and evaluating accurately the medical record and related documents of the members to assess any discrepancy in the billing of services or in regards to the justification of the procedure(s)
•Investigate suspected health insurance misuse and abuse cases related to Daman members, collecting necessary documentation and as required, evidence to support his/her evaluation of the case
•Ensure that business decisions and processes are documented in a professional manner with due confidentiality
•Prepare the final audit report following the on-site audit and investigation; communicate with the providers regarding the audit findings and initiates the corrective adjustments, if any
•Follow-up the recovery process related to the audited provider with Daman's Claims department until completion
•Understand all policies and procedures relevant to the claims cycle and the auditing of providers, liaise regularly with all Daman departments involved in the claims cycle as well as the Provider Relations department to understand current provider issues and observed billing trends
•Understand the local provider market and understands statistical analysis of provider behavior prepared by Daman's MSD department, commission specific data analysis as required by his/her audit plan
•Ensure that he is acquainted with the legal requirements pertaining to auditing of providers in the Emirate of Abu Dhabi and the U.A.E
•Offer technical support by continuous assessment and feedback concerning data quality and proper encoding of services
•Uphold the department's goals and values, and contribute to its efficient development and growth
•Ensure that medical ethics and professionalism are maintained during the fulfillment of all tasks
•Support the company's decisions and professionally represent Daman in Daman in aspects of dress code, punctuality, professionalism, etc.
Job Details
| Date Posted: | 2013-06-27 |
| Job Location: | Abu Dhabi, United Arab Emirates |
| Job Role: | Other |
| Company Industry: | Insurance |
Preferred Candidate
| Career Level: | Mid Career |
| Degree: | Baccalauréat / Diplôme supérieur |
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