Role Summary
The Medical Advisory, Case & Fraud Management Specialist is responsible for identifying patterns of fraud, waste, and abuse in medical claims. This role plays a crucial part in ensuring cost containment while maintaining the quality of care within the healthcare system.
Job Description
In this position, you will engage in daily activities that involve analyzing medical claims and collaborating with healthcare providers to mitigate risks. You will work in a dynamic environment that emphasizes teamwork and continuous improvement.
Key Responsibilities:
- Identify patterns of fraud, waste, and abuse in medical claims.
- Conduct surgical history checks to validate claims.
- Implement risk management measures to prevent fraudulent activities.
- Perform reviews of hospitalizations to ensure cost containment.
- Provide medical advisory on disputed charges and appeals.
- Maintain and enhance fraud analysis tools.
- Conduct training sessions for staff and healthcare providers.
- Mentor team members and support their professional development.
Job Requirements
Minimum Bachelor's Degree or Diploma in a relevant field.
At least 5 years of experience in medical claims processing.
Proficient in medical coding, MOH letters, and reasonable charges.
Strong knowledge of health insurance policies and medical reports.
Ability to identify breach of duty and non-disclosure in claims.
Experience in conducting audits and case management for fraud detection.
Quick Info
Company
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Location
Kuala Lumpur
Salary
—
Incentive / Bonus
Not specified
Skills Required
6 skills
Click to submit your application
Required Skills
Medical Coding
Fraud Detection
Risk Management
Data Analysis
Communication
Team Leadership
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