Senior Medical Network Relations Officer

Walaa Cooperative Insurance CompanyJeddah, Makkah Region, Saudi Arabia

17 منذ أيام

الوصف الوظيفي

Duties & Responsibilities

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.

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

Integrity & Ethical Mindset – Strong moral principles to handle sensitive financial and healthcare data responsibly.

Attention to Detail – Ability to spot anomalies, inconsistencies, and patterns in data.

Analytical Thinking – Logical approach to problem‑solving and decision‑making.

Critical Thinking – Evaluating evidence to determine fraud risks and compliance gaps.

Persistence & Patience – Fraud investigations and reconciliations can be complex and time‑consuming.

Communication Skills – Clear reporting of findings to internal teams, auditors, and regulators.

Confidentiality & Discretion – Handling sensitive patient and financial information with care.

Adaptability – Keeping up with evolving fraud schemes and regulatory changes.

Skills

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

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Senior Officer • Jeddah, Makkah Region, Saudi Arabia