The Position

Summary

The Senior, Claims Audit plays a critical role in safeguarding healthcare scheme integrity by identifying, analysing, and mitigating risks related to claims fraud, waste, abuse, and billing inaccuracies.

This role combines clinical auditing expertise, data analytics, and stakeholder engagement to ensure claims are accurate, compliant, and aligned with reimbursement policies. The incumbent will lead complex audits, generate actionable insights, and influence both internal and external stakeholders to strengthen claims governance and optimise healthcare spend.

Responsibilities

1) Claims Audit \& Risk Assessment

• Conduct detailed reviews of healthcare claims to assess clinical appropriateness, coding accuracy, and policy compliance.
• Identify patterns of fraud, waste, abuse, or billing anomalies through structured audits and analytics.
• Develop and execute audit plans for high-risk providers, services, and member claims.

2) Fraud Detection \& Investigations

• Analyse claims data, provider behaviour, and utilisation trends to uncover suspicious activities and systemic risks.
• Partner with fraud investigation and intelligence teams to support case development and resolution.
• Document findings, prepare audit reports, and provide evidence-based recommendations.

3) Stakeholder Engagement \& Advisory

• Engage with healthcare providers, industry bodies, and internal stakeholders to clarify audit findings and resolve discrepancies.
• Lead discussions on billing practices, coding standards, and policy interpretation.
• Provide expert advisory on claims governance and risk mitigation strategies.

4) Analytics, Insights \& Reporting

• Leverage data tools and dashboards (e.g., SQL, Power BI) to identify trends and emerging risks.
• Translate complex data into actionable insights to improve claims controls and cost management.
• Produce high-quality audit reports and executive summaries.

5) Risk Controls \& Continuous Improvement

• Design and recommend controls to mitigate claims leakage and reduce fraud exposure.
• Enhance audit methodologies, tools, and processes to improve efficiency and effectiveness.
• Contribute to the development of automated detection models and rule engines.

6) Project Management

• Lead complex or large-scale audit engagements end-to-end.
• Manage multiple priorities while ensuring timely delivery and high-quality outputs.

Candidate Profile

Experience and Qualifications

• Minimum 5–8 years of experience in claims auditing, clinical auditing, or healthcare fraud risk.
• Strong knowledge of medical coding systems and reimbursement policies (e.g., ICD, CPT, DRG equivalents).
• Experience in healthcare payer, insurance, or managed care environments preferred.
• Certification in Fraud Examination, Clinical Coding, or Audit is an advantage.
• Bachelor’s degree in healthcare (Medicine, Nursing, Pharmacy) or related discipline.

Competencies \& Core Characteristics:

We are seeking a leader who embodies the following competencies and characteristics essential for success in our scale-up environment:

• Technical Domain Expertise: Deep understanding of healthcare claims processes, clinical coding, and reimbursement frameworks, with the ability to identify risks and interpret complex cases.
• Execution Excellence: Demonstrates strong ownership, delivers high-quality work under pressure, and manages multiple projects effectively.
• Data-Driven Decisiveness: Uses structured analysis and data insights to make informed decisions and prioritise high-impact audit activities.
• Strategic Architect: Connects audit findings to broader organisational risks and contributes to long-term fraud prevention and cost optimisation strategies.
• Unifier \& Cross-Functional Influencer: Engages and influences providers, regulators, and internal teams with confidence and credibility to drive resolution and compliance.