Assistant Manager - Medical Fraud & Audit Infiniti Capital

Job PURPOSE:

To lead and manage medical claim audits, fraud investigations, and risk mitigation strategies by leveraging clinical and analytical expertise to detect, prevent, and recover fraudulent claims. Ensure cost containment, compliance with health insurance guidelines, and maintain the integrity of provider networks.

Key Responsibilities:

· Conduct in-depth audits of inpatient and outpatient claims to identify irregularities and fraudulent patterns.

· Investigate suspicious claims from providers or insured members and provide reports with findings and recommendations.

· Perform retrospective reviews of claims and recommend recovery actions where applicable.

· Utilize clinical background and health policy knowledge to evaluate the appropriateness of treatments and billing.

· Work closely with medical providers, claim processing teams, and IT to detect fraud and mitigate risks.

· Analyze large volumes of claims data to identify trends and generate actionable insights.

· Prepare detailed investigation and audit reports including recovery amounts, analysis findings, and fraud prevention measures.

· Develop and maintain dashboards for savings, turnaround time (TAT), and fraud indicators.

· Assist in provider evaluation, credentialing, and price negotiations based on performance, audit findings, and service delivery.

· Recommend exclusion or blacklisting of non-compliant providers based on audit outcomes.

· Recommend and support the implementation of automation tools and controls to enhance fraud detection capabilities.

· Contribute to policy updates and SOP enhancements to improve audit and investigation standards.

· Train and guide junior auditors or claim analysts in fraud indicators and audit methodology.

· Actively participate in cross-departmental meetings and share best practices.