Medical Provider Performance Executive

About the role

The Medical Provider Performance Executive leads investigations into potential fraud, waste, and abuse by healthcare providers affecting Allianz Group and its payers. The role requires independent judgment, strong analytical abilities, and the capacity to manage a high volume of complex cases while maintaining professional relationships with all stakeholders.

Key responsibilities

• Detect and prevent fraud, waste, and abuse by medical providers across assigned regions.
• Perform data mining and analysis of provider claims to identify irregularities.
• Gather evidence, document findings, and recommend actions to recover improper payments or deny unjustified claims.
• Participate in on‑site audits, in‑house claim reviews, and mystery‑shopping campaigns.
• Prepare comprehensive investigative reports and periodic dashboards.
• Collaborate with legal, finance, claims operations, and external clients or providers.
• Consult with regulatory authorities when investigations may lead to legal action.
• Support the Medical Provider Performance Manager with administrative tasks to drive fraud detection.

Required profile

• Medical background such as MBBS, nursing, or paramedic qualification.
• Relevant coding certifications (e.g., CPC, CPMA, COC, CCS).
• Experience in the insurance industry with claim cycle management.
• Strong analytical mindset and ability to work independently.

Required skills

• Advanced Excel
• Power BI
• Data analytics