JOB DESCRIPTION AND EXPECTATIONS
- Responsible for ensuring the Care Check program achieves its claims savings target through rigorous quality assurance, data integrity management, and fraud pattern detection. This role drives operational excellence by monitoring call quality, identifying systemic fraud trends, correcting data inaccuracies, and providing actionable insights that enable the team to prevent fraudulent and inappropriate claims before they are paid.
Academic/Professional: Bachelor’s degree in healthcare, Business, Statistics, Data Analytics, or related field from a reputable Tertiary Institution, master’s degree, MBA, or certifications in fraud investigation, Six Sigma, healthcare quality is an advantage.
Work experience: 1 -4 Years in Experience conducting quality audits or monitoring.
Job Level: This position has been profiled as a minimum Analyst role owing to the defined skill level, years of experience and complexities of the task to be performed.
Grade Level: This position has been profiled as a minimum Grade Level 8 owing to the defined skill level, years of experience and complexities of the task to be performed.
Key Responsibilities
- Score calls using standardized quality framework (accuracy, professionalism, fraud detection)
- Provide weekly feedback to supervisors for agent coaching
- Conduct calibration sessions to ensure consistent quality standards
- Design and deliver training on fraud detection and validation techniques
- Conduct trend analysis by service type, provider specialty, geographic location, and temporal patterns
- Liaise with IT/Data Management to fix systemic data issues
- Investigate and resolve wrong personal IDs (enrollees with mismatched identities)
- Design and deliver training on fraud detection and validation techniques
- Liaise with IT/Data Management to fix systemic data issues
- Track progress toward 1.5% claims savings target
- Deliver presentations on savings, quality, and fraud trend
- Monitor regulatory compliance (data privacy, consent protocols)
- Analyze savings by provider, service type, team, and period
- Calculate daily, weekly, monthly savings (value of encounters suspended/retracted)
- Prepare daily, weekly, and monthly performance dashboards
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