Job Description

• Job Summary:
  We are seeking a highly skilled Medical Claims Adjudicator with strong expertise in
  utilization data analysis, medical and financial rules, and fraud, waste, and abuse
  (FWA) detection. The role is responsible for accurately reviewing, analyzing, and
  adjudicating medical claims (inpatient and outpatient ) in compliance with medical
  policies, medical rules, reimbursement rules, and regulatory requirements, while
  proactively identifying abnormal utilization patterns and potential fraud or abuse cases.

  Key Responsibilities:

• Review, analyze, and adjudicate medical claims in accordance with:
• Medical policies and clinical guidelines
• Utilization management rules
• Contractual and financial rules
• Perform utilization data analysis to:
  o Identify overutilization, underutilization, and inappropriate services
  o Detect unusual provider or member behavior patterns
  (constellations/pattern analysis)
• Apply medical coding and billing rules (e.g., ICD, CPT, HCPCS….).
• Validate medical necessity, appropriateness of care, and level of service
• Analyze claim trends and utilization metrics to support cost containment and
  quality assurance.
• Identify, document, and escalate suspected fraud, waste, and abuse (FWA)
  cases in line with internal protocols.
• Ensure compliance with regulatory requirements, payer policies, and internal
  SOPs.
• Prepare clear documentation, reports, and recommendations related to claim
  decisions and FWA findings.
• Support audits, internal reviews, and continuous improvement initiatives.

Requirements

• Bachelor’s degree in a relevant field (e.g., Medicine/ Pharmacy).
• Minimum 2 years of experience in:
• Medical claims adjudication
• Utilization review or utilization management
• Strong knowledge of:
  o Medical necessity criteria and clinical guidelines
  o Healthcare reimbursement and financial rules
  o Claims payment logic and adjudication workflows
   Demonstrated experience in detecting or supporting investigations of fraud,
  waste, and abuse.

Required Skills & Competencies:
Technical & Analytical Skills


• Utilization data analysis and interpretation
• Pattern/constellation analysis for abnormal claim behavior
• Strong understanding of medical coding systems (ICD, CPT, HCPCS)
• Knowledge of healthcare payment methodologies
• Ability to analyze large datasets and identify trends or outliers
• Advanced skills in data analysis tools (Excel, BI tools,….)

  Medical & Regulatory Knowledge

• Medical rules and clinical guidelines
• Healthcare compliance and regulatory frameworks
• Fraud and abuse indicators and red flags