Manager - Claims Integrity

About the Role

As a Manager in Claims Integrity, you will conduct thorough examinations and analyses of fraud, waste, and abuse (FWA) cases, alerts, claim patterns, and emerging trends within the healthcare market. Your role ensures precise evaluations, proper documentation of evidence, supports decision-making processes, enables effective recovery follow-ups, and contributes insights towards enhancing Claims Integrity controls and operational workflows.

Key Responsibilities

• Inspect and analyze FWA-related cases, alerts, suspicious claims patterns, and unusual behaviors of providers and members.
• Evaluate claim specifics, medical justifications, billing habits, and associated evidence to detect possible FWA issues.
• Accurately document findings to aid decisions, recoveries, escalations, or further investigations.
• Prepare collected data and evidence to support negotiation efforts regarding fraudulent claims with the provider relations team.
• Engage with provider relations to substantiate evidence and negotiate recoveries to achieve projected targets.
• Complete necessary reports and proceed with escalation to regulatory bodies when required.
• Examine recurring claims behaviors, provider trends, and emerging FWA market patterns to identify new or evolving abuse schemes.
• Offer insights and recommendations to refine Claims Integrity detection controls, rules, and review procedures.
• Assist in recovery follow-up by supplying validated evidence, logical rationale, and coordinating with stakeholders to ensure appropriate action.
• Provide constructive feedback on gaps in operations, false positives, challenges during reviews, and opportunities for improvements.

Qualifications and Skills

• Minimum 2 years of experience in medical practice and insurance environments.
• Strong analytical and investigative abilities to recognize suspicious activities, market trends, and control deficiencies.
• Exceptional documentation skills to prepare concise case summaries, evidence packages, findings, and support materials for decision-making.
• Problem-solving aptitude for proposing practical enhancements to Claims Integrity measures and operational processes.
• Excellent communication and coordination skills to collaborate effectively with Claims Integrity teams, medical staff, provider management, recovery, and other operational units.
• Medical Bachelor's degree (M.B; B.S./M.D. or equivalent) required.
• In-depth understanding of claims integrity concepts, FWA, medical auditing, claims operations, and healthcare insurance controls.
• Proficiency in reviewing and analyzing FWA cases, alerts, claims patterns, provider conduct, and supporting documentation.
• High attention to detail with a strong commitment to accuracy, evidence quality, consistency, and auditability.
• Working knowledge of claims systems, case management platforms, dashboards, Excel, and reporting tools is preferred.
• Digital skills to effectively utilize claims systems, tools, and reporting platforms for case review and pattern analysis.