Claims Review & Analysis

• Review medical and pharmaceutical claims to identify potential fraud, waste, or abuse.
• Analyze prescription patterns, drug utilization, and treatment protocols for irregularities.
• Validate diagnosis–treatment–medication alignment to ensure medical necessity and accuracy.

Investigation & Reporting

• Conduct detailed investigations into suspicious claims submitted by providers, pharmacies, or members.
• Gather and analyze supporting documentation (prescriptions, invoices, medical reports).
• Prepare clear, evidence-based investigation reports and recommend actions.

Data Monitoring & Fraud Detection

• Monitor utilization trends using system tools and dashboards.
• Identify red flags such as duplicate claims, excessive dispensing, altered prescriptions, or mis-coded services.

Stakeholder Coordination

• Coordinate with medical providers, pharmacies, and internal departments to verify claim details.
• Liaise with insurance/TPA audit teams when escalations or recoveries are required.

Compliance & Governance

• Ensure all investigations comply with medical regulations, TPA policies, and insurance guidelines.
• Stay updated on new pharmaceutical products, pricing, generic vs. brand guidelines, and common fraud schemes.