Job Description

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.

Internal KPIs:

These measure the company’s internal performance and effectiveness in detecting, managing, and preventing FWA, as well as ensuring the reconciliation process runs smoothly.

1. Fraud Detection Rate:

• Percentage of fraud cases detected vs. total fraud cases identified in the system.

1. Investigations Completed on Time:

• Percentage of fraud investigations that meet the predefined time frame for completion.

1. Case Resolution Time:

• Average time it takes to resolve FWA cases (from detection to resolution).

1. Recouped Amount:

• Total monetary value recovered from fraud, waste, or abuse incidents.

1. Employee Compliance:

• Percentage of employees adhering to internal fraud prevention and detection protocols.

1. Audit Effectiveness:

• Percentage of claims audited that result in identified issues (fraudulent, wasteful, or abusive practices).

1. Training Completion Rate:

• Percentage of relevant staff completing FWA prevention and detection training programs.

1. Reconciliation Accuracy:

• The percentage of claims and payments reconciled without discrepancies.

1. Rework Rate:

• Percentage of claims that require rework due to discrepancies in data or processes.

1. False Positive Rate:

• Percentage of flagged cases that are ultimately found to be non-fraudulent.

External KPIs:

These focus on how the company performs in relation to external stakeholders, such as regulatory bodies, providers, and members.

1. Regulatory Compliance:

• The company’s adherence to legal and regulatory requirements for fraud detection and reconciliation processes.

1. Provider Compliance:

• Percentage of providers adhering to fraud prevention measures and ethical billing practices.

1. Member Satisfaction:

• Customer satisfaction scores related to claim disputes, fraud-related issues, and the claims reconciliation process.

1. Third-Party Audits:

• Results from audits conducted by external parties, including compliance checks and assessments of FWA detection systems.

1. Claim Denial Rate (due to FWA):

• Percentage of claims denied due to fraud, waste, or abuse detection.

1. Legal Actions/Settlements:

• Number of legal actions or settlements related to FWA, including lawsuits or settlements with external parties.

1. Reimbursement Recovery:

• Total amount recovered from external parties such as providers or members due to fraudulent claims.

1. External Stakeholder Feedback:

• Feedback from insurance agents, healthcare providers, or regulatory bodies about the effectiveness of the FWA prevention program.

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:

1. Integrity & Ethical Mindset – Strong moral principles to handle sensitive financial and healthcare data responsibly.
2. Attention to Detail – Ability to spot anomalies, inconsistencies, and patterns in data.
3. Analytical Thinking – Logical approach to problem-solving and decision-making.
4. Critical Thinking – Evaluating evidence to determine fraud risks and compliance gaps.
5. Persistence & Patience – Fraud investigations and reconciliations can be complex and time-consuming.
6. Communication Skills – Clear reporting of findings to internal teams, auditors, and regulators.
7. Confidentiality & Discretion – Handling sensitive patient and financial information with care.
8. Adaptability – Keeping up with evolving fraud schemes and regulatory changes.

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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Requirements added by the job poster

• No need for visa sponsorship

• 3+ years of experience in Health Care Provider