Quality Assurance Manager – Health

About the role

The Health Insurance Quality Assurance Manager ensures that claims, case processes, and related services meet established standards. The role focuses on efficiency, loss mitigation, and cost control while handling complex client enquiries.

Key responsibilities

• Perform quality audits of claims, with emphasis on high‑value, repeated, and duplicate submissions.
• Identify providers with billing irregularities or suspected fraud and conduct regular engagements.
• Review admissions for exaggerated or unnecessary bills and monitor integration exception reports between E02 and D365.
• Conduct trend analysis, detect leakage, and produce objective reports on claims and case processing.
• Enforce cost‑control measures such as copayments, discounts, provider restrictions, and waiting periods.
• Maintain compliance with SOPs for claims, case, and provider management.
• Manage reserve philosophy for admissions and enhanced amounts, and review IP bills monthly.
• Develop competency‑based training, identify knowledge gaps, and drive remediation actions.
• Prepare regular claims reports for management and support underwriters in medical risk review.
• Investigate suspected fraud, guide reporting to GFS, and ensure timely resolution of disputes.

Required profile

• Proven experience in health‑insurance claims auditing and quality assurance.
• Strong analytical mindset with ability to conduct trend and leakage analysis.
• Experience in fraud detection and investigation within a medical claims environment.
• Ability to coach and train less‑experienced staff.

Required skills

• Microsoft Dynamics 365 (D365)
• E02 claims processing system
• Data analysis and trend reporting
• Audit methodology for health‑insurance claims
• Fraud investigation techniques