About the Role

Bupa Arabia is seeking a Manager - Claims Integrity to join its team in Riyadh. This is a full-time position designed for a professional with 2-5 years of experience in the field. The role focuses on safeguarding the integrity of claims processes by identifying, analyzing, and addressing instances of fraud, waste, and abuse (FWA).

Role Purpose

The Manager - Claims Integrity is responsible for performing detailed reviews and analyses of FWA-related cases, alerts, claims patterns, and emerging market trends. This position ensures accurate assessment, thorough evidence documentation, and provides critical support for decision-making and recovery efforts, while also contributing to the continuous improvement of Claims Integrity controls and processes.

Key Responsibilities

• Review FWA-related cases, alerts, claims patterns, and suspicious provider/member behaviors.
• Assess claim details, medical justifications, billing patterns, and supporting evidence to identify potential FWA concerns.
• Document findings clearly to support decisions, recoveries, escalations, or further review.
• Analyze repeated claims behaviors, provider trends, market practices, and emerging FWA patterns.
• Identify new or evolving abuse behaviors that may require new controls, rules, reviews, or process changes.
• Provide observations and feedback to support enhancement of Claims Integrity controls and detection logic.
• Support recovery follow-up by providing validated findings, evidence, and business rationale.
• Coordinate with relevant stakeholders to ensure review outcomes are actioned appropriately.
• Provide feedback on operational gaps, false positives, review challenges, and improvement opportunities.

Fraudulent Case Management and Negotiation

A significant aspect of this role involves the management and negotiation of fraudulent cases. Specific duties include:

• Arrange collected data and evidence for negotiation and decision-making.
• Discuss evidence with the Provider Relations Team for substantiation.
• Negotiate with the Provider Relations Team to achieve recovery targets.
• Complete necessary reports and prepare files for escalation to regulators.

Qualifications and Requirements

• Bachelor's degree in Medicine (; ***** or equivalent).
• A minimum of 2 years of experience in medical practice and insurance.

Application Information

Bupa Arabia invites qualified candidates who meet the specified requirements to apply for this role.