Assistant Manager – Medical Fraud, Waste & Audit

We have an urgent requirement for Assistant Manager – Medical Fraud, Waste & Audit is required for one of our client in Oman

Experience in medical claims, audits, or insurance fraud detection.---Must

Experience working in GCC healthcare--Must

Job PURPOSE

To lead and manage medical claim audits, fraud investigations, and risk mitigation strategies by leveraging clinical and analytical expertise to detect, prevent, and recover fraudulent claims. Ensure cost containment, compliance with health insurance guidelines, and maintain the integrity of provider networks

Key Responsibilities

• Conduct in-depth audits of inpatient and outpatient claims to identify irregularities and fraudulent patterns.
• Investigate suspicious claims from providers or insured members and provide reports with findings and recommendations.
• Perform retrospective reviews of claims and recommend recovery actions where applicable.
• Utilize clinical background and health policy knowledge to evaluate the appropriateness of treatments and billing.
• Work closely with medical providers, claim processing teams, and IT to detect fraud and mitigate risks.
• Analyze large volumes of claims data to identify trends and generate actionable insights.
• Prepare detailed investigation and audit reports including recovery amounts, analysis findings, and fraud prevention measures.
• Develop and maintain dashboards for savings, turnaround time (TAT), and fraud indicators.
• Assist in provider evaluation, credentialing, and price negotiations based on performance, audit findings, and service delivery.
  
  

Qualifications & Certifications

• M.B.B.S. (Bachelor of Medicine, Bachelor of Surgery) or B.A.M.S. (Bachelor of Ayurvedic Medicine and Surgery.
• Certification in Fraud Detection, Health Insurance, or Risk Management.
  
  

Experience

• Minimum 5–7 years in medical claims, audits, or insurance fraud detection.
• Proven track record of successful fraud investigations and recoveries.
• Experience working in GCC healthcare insurance system
  
  

Key Skills

• Medical auditing & claims investigation
• Fraud detection and analytics
• Data analysis & report writing
• Strong knowledge of medical terminology, coding, and treatment protocols
• Network/provider management
• Regulatory compliance in health insurance
• Excellent communication, negotiation, and stakeholder handling skills
• Time management and ability to handle sensitive cases with confidentiality
• Advanced proficiency in MS Excel, including VLOOKUP, pivot tables, conditional formatting, and data analysis tools
  
  

Skills: manager,regulatory compliance in health insurance,data analysis & report writing,coding and treatment protocols,medical auditing & claims investigation,time management,negotiation skills,advanced proficiency in ms excel,excellent communication skills,medical,fraud,network/provider management,fraud detection and analytics,strong knowledge of medical terminology,stakeholder handling skills