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Manager, Medical, Fraud & Knowledge Management

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Manager, Medical, Fraud & Knowledge Management
Company:

Aia


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Manager, Medical, Fraud & Knowledge Management

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Details of the offer

Bring your career aspirations to life with AIA!
To be part of the medical audit team. To review cases referred from the claims team – review of hospital and doctor’s charges.
1. Adherence to reasonable and customary charges and doctor’s charges in compliance with the 13th Schedule (PHFSA) by providing medical advisory, interpretation of the product content and intent to the payment of the claims.
a. To ensure adherence to turn around time & service level agreements with hospitals.
b. To provide medical advisory to the claims team.

2. To provide and monitor trends in the industry.
a. Conducts trending of providers based on cost / admission length/ admission type/ areas for improvement.
b. Trends doctor’s charges and reviews charging behaviour to establish over utilization – which is supplementary to the provider conversation and trending reports. Updates AIA Health Services on a weekly basis.
c. Collation of reasonable and customary charges within the industry to ensure that charges are within benchmark.

3. Collates trends and flags out cases for provider conversations while ensuring inter-conversation cadence is maintained through scheduled feedback.
Responsibilities:
To be part of the medical audit team. To review cases referred from the claims team – review of hospital and doctor’s charges.
1. Adherence to reasonable and customary charges and doctor’s charges in compliance with the 13th Schedule (PHFSA) by providing medical advisory, interpretation of the product content and intent to the payment of the claims.
a. To ensure adherence to turn around time & service level agreements with hospitals.
b. To provide medical advisory to the claims team.
2. To provide and monitor trends in the industry.
a. Conducts trending of providers based on cost / admission length/ admission type/ areas for improvement.
b. Trends doctor’s charges and reviews charging behaviour to establish over utilization – which is supplementary to the provider conversation and trending reports. Updates AIA Health Services on a weekly basis.
c. Collation of reasonable and customary charges within the industry to ensure that charges are within benchmark.

3. Collates trends and flags out cases for provider conversations while ensuring inter-conversation cadence is maintained through scheduled feedback.
a. Collates cases based on conversation theme e.g: High surgical cost/high implant cost.
b. Provides recommendations and controls to manage healthcare inflation.
c. Advices provider team as and when necessary in relation to policy holder and provider feedback.
4. Other duties: Transformation office initiatives contributor / Medical Advisory for TPD and CI for member claims.
5. In charge of analysis on emerging patterns and trends in medical Fraud, Waste and Abuse (FWA) practices.
• Facilitate and implement controls on FWA prevention and minimization of billing wastages.
• Oversee and improve upon current methodology for FWA detection, resolution and prevention.
• Provide medical insights to various divisions within AIA such as Health Claims Management, Network Management and Healthcare Strategy, Corporate Solutions, and Customer Experience.
• Conduct training and provide feedback on FWA related matters to internal and external stakeholders.
• Provide recommendations to curb FWA practices based on analysis of emerging patterns and trends observed.
6. To build and refine guides and SOPS in terms of technical Insurance and Medical knowledge.
7. To conduct medical training and improve medical and technical knowledge among assessors.

MIDDLE MANAGEMENT
To lead, coach, supervise and establish processes, work flow and follow up on medical audit cases and the case management team.
Review and coordinate cases that require the involvement and escalation to providers and internal stakeholders.
To provide medical advisory and guidance to the Case Management team and the Health Claims Management.
To support operations of the Health Claims Management team.

To assist in Fraud, Waste and Abuse initiatives.
To lead, coach, supervise and establish processes, work flow and follow up on medical audit cases and the case management team.
Review and coordinate cases that require the involvement and escalation to providers and internal stakeholders.
To provide medical advisory and guidance to the Case Management team and the Health Claims Management.
To support operations of the Health Claims Management team.

Build a career with us as we help our customers and the community live healthier, longer, better lives.

You must provide all requested information, including Personal Data, to be considered for this career opportunity. Failure to provide such information may influence the processing and outcome of your application. You are responsible for ensuring that the information you submit is accurate and up-to-date.

Requirements

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