About The Role

• Responsible for detecting Fraud, Waste and Abuse for AIA.
• To conduct analysis with proper cost containment measures, recovery, and process improvements.
• To build guides, initiatives, and alignment of claims practices related to cost savings and quality claims processing.
• Medical Training and Medical Advisory within and beyond AHS.
• To ensure SOPS are updated periodically.
• To support TDA/Squads and other projects as required.
• To ensure the Fraud tool is maintained and managed with care with insightful monthly analysis.
• Well-versed with medical coding, 13th Schedule, MOH letters, reasonable and customary charges.
• To conduct regular audits, and handle escalations to identify Fraud, Waste and Abuse.
• To ensure claim adjudication is in accordance with reasonable and customary charges.
• To review trending of doctors who may or may not be in the watch list.