Regional Healthcare FWA (Fraud, Waste and Abuse) Manager

Job Description

GIG Gulf is part of the Gulf Insurance Group (GIG), the #1 largest regional composite insurer in the Middle East and North Africa, with presence in 13 markets including the United Arab Emirates, Bahrain, Oman, Qatar, Saudi Arabia, Algeria, Egypt, Iraq, Jordan, Kuwait, Lebanon, and Turkey. GIG Group reported consolidated assets of US$ 3.83 billion and $69 million net profit for the year 2023. The majority shareholder of GIG Group is Toronto based Fairfax Financia Holding, a global leader in insurance and reinsurance with a presence in 40 markets.

GIG Gulf is an ‘A’ rated regional insurer with a top 5 position in each of its markets (UAE, Oman, Qatar, Bahrain). GIG Gulf has been present in the region for over 70 years with a strategic focus on both growth and investments and is a one stop shop offering a wide range of insurance products and services that cater to a broad variety of needs for corporates, SMEs and individual customers throughout UAE, Oman, Bahrain, and Qatar. GIG Gulf also owns a 50% stake in GIG Saudi. Our strategic objectives and guiding principles are focused on Regional Growth, Customer Experience and Digital Transformation.

GIG Gulf has created a diverse and inclusive working environment and culture with a workforce of over 800 employees, with over 60 nationalities, across 15 branches and retail shops region-wide and over 1 million customers. GIG Gulf is a caring partner that encourages customers to achieve their goals and live an inspiring and fulfilling life. We are obsessed with customer feedback and continuously evolving to become the region’s digital insurer of reference, committed to running our operations in a responsible, sustainable way.

Job purpose:

The Regional FWA Manager is responsible for overseeing, managing, and implementing fraud, waste, and abuse (FWA) detection, prevention, and investigation programs across a designated region. This role is crucial in ensuring the integrity of the healthcare claims process by identifying suspicious activity, mitigating risks, and collaborating with key stakeholders to develop strategies that combat FWA in health insurance operations. The Regional FWA Manager will lead a team of investigators, analysts, and auditors while ensuring compliance with regulatory and payer-specific requirements.

Key Responsibilities

• Develop, implement, and manage strategies for identifying and mitigating fraud, waste, and abuse in health insurance claims.
• Oversee the use of data analytics and advanced detection tools to monitor and flag unusual patterns in claims submissions.
• Collaborate with underwriting, claims, medical management, and legal teams to ensure seamless integration of FWA prevention efforts.
• Lead and coordinate detailed investigations of suspicious claims and provider practices to determine the validity of claims.
• Manage regional audit processes, ensuring that audits are effectively conducted to detect fraudulent or abusive activities.
• Conduct or coordinate on-site and desk audits of healthcare providers, as required.
• Ensure compliance with regional, national, and international health insurance regulations related to FWA, including local governing bodies, anti-fraud laws, and healthcare standards.
• Keep updated on regulatory changes and ensure that FWA strategies comply with the latest regulations.
• Lead, mentor, and manage a team of FWA investigators, analysts, and auditors.
• Provide ongoing training and development to staff on FWA detection methods, emerging trends, and regulatory changes.
• Identify and assess potential areas of vulnerability and risk in claims management processes, providing recommendations for corrective actions.
• Work with senior management to develop and implement risk mitigation strategies across the region.
• Work closely with healthcare providers and internal teams to promote a culture of compliance.
• Prepare detailed reports on FWA findings, including case summaries, action plans, and recommendations.
• Ensure proper documentation of all FWA investigations and audits, maintaining compliance with data protection.
• Leverage data intelligence platforms to analyze healthcare claims data and identify emerging FWA trends.
• Oversee the development of provider profiles and scoring models to prioritize high-risk providers for audits and investigations.
• Stay informed about industry trends and best practices in fraud detection and prevention in health insurance.
• Manage the Clinical Governance Teams and Medical Guidelines Updates.
• Attend Regulatory Meeting tackling new guidelines and circulars.
• Periodically travel to audit the providers across the region countries where GIG Gulf operates

Role Requirements:

Essential:

• Completed bachelor’s degree in medicine.” MBBCH”
• At least 5 years’ experience in a similar role in the Healthcare Audit with coding experience.
• Excellent skills in data analysis and using Microsoft office, mainly Excel, Power point and Word.
• 2-3 Years in management role and proven leadership experience with the ability to motivate & guide a team.
• Proficient Knowledge of the UAE/Gulf healthcare Insurance market.
• Proficient Knowledge of UAE/Gulf countries healthcare providers trends and behaviors.
• Proficient Knowledge of the UAE/Gulf legislations and regulations.
• Sound knowledge of medical claims adjudication.
• Coding certification/HealthCare Providers Audit Certificate
• Leadership and Communication.
• Analytical and Problem-Solving Abilities.
• Ability to travel within the region as needed.

Desirable:

• Risk Management and Mitigation
• Analytical Thinking and Decision-Making
• Communication and Stakeholder Management
• Strategic Planning and Execution

Benefits found in job post

Medical insurance