Senior, Claims Audit

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 & Investiga...