Manager - Claims Integrity

Bupa Arabia
Riyadh
Workplace: OnsiteFull timeFunction: Insurance & ActuarialExperience: 2+ yearsEducation: bachelorsSkills: ["Analytical","Investigative","Documentation","Problem-solving","Communication","Stakeholder coordination","Attention to detail"]

Review and analyze FWA-related cases, alerts, and claims patterns to ensure accurate assessment, evidence documentation, and decision support. Investigate suspicious provider/member behaviors, prepare and present evidence for recovery negotiations with provider relation teams, and escalate required findings to regulators. Monitor market and behavioral trends to identify emerging abuse patterns, then feed observations into Claims Integrity controls and process improvements while supporting recovery follow-up with stakeholders.

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FursaFursa
Bupa Arabia
Bupa Arabia
6 days ago

Manager - Claims Integrity

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Source: Company careers pageValidated by: Fursa AI
Last checked: 4 hours agoStatus: Live

Job Summary

Review and analyze FWA-related cases, alerts, and claims patterns to ensure accurate assessment, evidence documentation, and decision support. Investigate suspicious provider/member behaviors, prepare and present evidence for recovery negotiations with provider relation teams, and escalate required findings to regulators. Monitor market and behavioral trends to identify emerging abuse patterns, then feed observations into Claims Integrity controls and process improvements while supporting recovery follow-up with stakeholders.
Location: Riyadh
Workplace: Onsite
Employment Type: Full time
Job Function: Insurance & Actuarial
Seniority: Manager level

Key Responsibilities

  • •Review FWA-related cases, alerts, claims patterns, and suspicious provider/member behaviors to assess claim details, medical justifications, billing patterns, and evidence.
  • •Document findings to support decisions, recoveries, escalations, or further review.
  • •Arrange collected data and evidences and support negotiations/decision-making with the provider relation team for needed recoveries.
  • •Analyze repeated claims behaviors and emerging FWA patterns, and provide observations and feedback to enhance Claims Integrity controls and detection logic.
  • •Support recovery follow-up by coordinating with stakeholders, providing validated evidence and business rationale, and escalating necessary reports to regulators.

Key Requirements

  • •2 years of medical practice and insurance experience.
  • •Analytical and investigative skills to identify suspicious patterns, emerging market trends, and potential control gaps.
  • •Strong documentation skills to prepare case summaries, evidence packs, findings, and decision-support inputs.
  • •Bachelor’s degree in Medicine (M.B; B.S./M.D or equivalent).
  • •Understanding of claims integrity, FWA, medical audit, claims operations, or healthcare insurance controls.
Experience:2+ yearsHealthcare insuranceFWAClaims integrity
Education:Bachelor's
Skills:AnalyticalInvestigativeDocumentationProblem-solvingCommunicationStakeholder coordinationAttention to detail
Tech Stack:Claims systemsCase management toolsDashboardsExcelReporting tools

Company Brief

Bupa Arabia
Provides health insurance products and managed healthcare services in Saudi Arabia for individuals and corporate clients. The company focuses on coverage administration, medical network access, and digital health support for members.
Industry: Health Insurance (Payers)
Company Size: Large (251 to 1,000 employees)
Growth: Public Company
Valuation: Public Company (Market Cap in USD)
Funding: IPO / Publicly Listed
Headquarters: Jeddah, Saudi Arabia
Founded: 1997
WebsiteLinkedIn