Senior Officer- Clinical Audit (Medical Provider Audit)

Transguard Group was established in 2001 and has diversified significantly, we lead in the fields of Cash Services, Security Services, Manpower Services, Facilities Management & Aviation. Transguard Group is the UAE’s most trusted business support and outsourcing provider and has a large, dynamic and culturally diverse workforce with 50,000 employees! We are currently recruiting for a Senior Officer- Clinical Audit (Medical Provider Audit) for our client to be based out of their Abu Dhabi office.

Purpose- 

To execute strategies under guidance of Manager to sample, analyse, identify and audit medical (including dental where relevant) claims to reduce fraud, wastage, abuse or errors (FWAE) from providers. Makes best use of tools made available for analytics and research to detect and control cases while ensuring smooth operations including compliance with insurance policies and set company standards, procedures and guidelines and provisions of regulatory bodies and Provider Contracts.

Job Responsibility-

• Follows medical audit operational procedures, Insurance Policies, Regulator guidelines Policy on fraud and abuse, and monitors their adherence so that work is carried out in a controlled manner.
• Develops and updates procedures manuals to maintain standards for correct coding, minimize the risk of fraud and abuse, and optimize revenue recovery.
• Performs day-to-day operations of remote and on-site Audit of medical / dental claims to detect misuse/abuse/fraud/errors and ensure that work processes are implemented as designed and comply with established standards and procedures and desired recoveries/ results are achieved.
• Evaluates medical records documentation to ensure the diagnostic and procedural codes accurately reflects and supports the reason for encounter and to ensure that data comply with legal standards and guidelines.
• Interprets medical information such as disease or symptoms, and diagnosis descriptions and procedures for a given visit in order to accurately assign and sequence the correct ICD 9/10 CM and CPT codes.
• Ensures to justify with documents and billing rules the stand formulated on coding related disputes with Provider.
• Assists the Manager in issuing monthly audit recoveries
• Prepares monthly remote and on-site Audit Plans.
• Prepares Audit saving Reports.

Minimum Qualifications and Knowledge

• Minimum Bachelor’s Degree either in medicine or dentistry /paramedic/ healthcare industry
• CPC/CPMA
• Requires 3 to 5 years of relevant experience
• Full Professional Proficiency in English language

This position profile indicates in general the nature and levels of work, knowledge, skills, abilities, and other essential functions expected of an employee. An employee may be asked to perform other duties as required which are within the scope, spirit, and purpose of the position profile. The employee shall also adhere to TRANSGUARD’S information security policies and procedures and the policies and procedures applicable to their area of responsibility.