Analyst, Fraud Waste and Abuse

  • Lagos

Objective and Responsibilities of the Unit:

The objective of the team is to continuously review and monitor the health portfolio to ensure fraud, waste, and abuse are generally reduced, if not eliminated, and subsequently enhance the profitability of the portfolio.

The team will serve as the liaison between the fraud, waste, & abuse team and the stakeholders (internal & external customers) to understand the business requirements and provide the support needed to ensure reduced care costs and increased revenues.

The Job function cut across collection of daily reports on suspicious activities from claims team, investigation of claim bills submitted by providers, review of all reimbursement bills, development of corrective actions and penalties associated with violations, identifying, and handling all suspicious or problematic insurance claims while providing consultation and strategic directions through professional reports

Job Grade Level: Analyst
Reports To: Head, Fraud Waste & Abuse
Supervises: Intern if required/available
Other Relationships (Internal & External): Business Development, Enrolment, Claims, Customer Care, Finance, Care Providers, Underwriting, Technology, Call Centres

RESPONSIBILITIES

Business Analysis: 

  • Conduct objective, fair, thorough, unbiased, and timely investigations into allegations of fraud, waste or abuse committed by clients against our company
  • Review and research evidence/documents to analyse the overall fact pattern of claim and synthesize data into a professional report with
  • Prepare and coordinate field assignments to obtain relevant evidence and information
  • Manage and prioritize a large and varied caseload effectively and efficiently to achieve positive results
  • Ensures compliance with all requirements related to fraud, waste, & abuse investigations
  • Conducts investigations for potential fraud, waste, & abuse with a focus on attention to detail, quality, timeliness, and cost control
  • Performs research using the internet, data analysis tools, etc., to analyse aberrant claims billing and practice patterns
  • Serves as a Subject Matter Expert for ICD, CPT coding issues
  • Provides monthly reporting/updates of all activities carried out
  • To ensure providers engaged in suspicious FWA activities are detected and prevented

Others: 

  • Thorough archiving and documentation of work and self-appraisal of work done to ensure that it is correct, complete, and logical.
  • Any assigned projects within the company
  • Drafting departmental procedure documents
  • Preparation of other management information as required.

KEY PERFORMANCE AREAS:

  • Internal & External Customer Satisfaction index
  • Business Process Improvement/Alignment
  • Process Time/output
  • Process Quality

JOB REQUIREMENTS
Education/Professional Qualification:

  • Bachelor’s Degree in Actuarial Science, Insurance, Mathematics, Statistics, or related field
  • Intermediate knowledge of Microsoft
  • Knowledge of VBA, Access, and R is a plus.

Experience: 1-3 years’ experience in a related position.

KEY SKILLS & COMPETENCIES REQUIREMENTS
Priority/Technical:

  • Knowledge of the insurance industry, business, sales, and claims processes, and providers’ operations.
  • A developed understanding of all Bastion’s products applicable to the Unit and underwriting applications
  • Ability to thoroughly investigate and ask questions when necessary to help the audit processes.
  • Required to work closely with all internal teams, ability to engage and manage relationships and fostering collaborations to achieve required results
  • To age one’s own workload and proactively provide
  • Ability to influence stakeholders/work closely with them to determine acceptable solutions.
  • Strong Communication, planning, & Organising skills
  • Organizational & excellent documentation skills
  • Experience in creating detailed business analysis
  • Proven ability to meet/exceed targets and deadlines and follow through on commitments
  • Technology Savvy with strong Ms Office Skills (Word, Excel, Outlook, Visio)
  • Data & Business Analysis Skills
  • Customer Service & Presentation Skills
  • Problem Solving Skills
  • Teamwork

Behavioral:

  • Demonstrable track record of first principles thinking
  • Honest and ethical with high levels of integrity and confidentiality
  • Be detail-oriented.
  • Confident
  • Innovative
  • Excellent organizational, prioritizing, time management, and multitasking skills.

 

To apply for this job email your details to career@afya.care