Job Description

Roles & Responsibilities

FWA Oversight & Risk Management

Lead the oversight of FWA detection and prevention processes , including governance of tools, rules, and investigation frameworks

Drive timely escalation, investigation, and closure of suspected FWA cases , in coordination with relevant stakeholders including TPA.

Continuously enhance FWA controls, analytics, and reporting frameworks in conjunction with TPA governance.

TPA Governance & Performance Management

Act as a central governance point for TPA operations , ensuring adherence to SLAs, KPIs, and contractual requirements

Monitor and assess TPA claims adjudication quality, accuracy, and consistency

Conduct periodic governance reviews and performance assessments of TPAs

Provider Network Performance Oversight

Oversee provider performance and billing behavior through TPA data and insights

Perform network provider onsite & offsite audits

Support implementation of corrective actions, cost containment strategies, and provider engagement initiatives

Stakeholder Management & Collaboration

Collaborate with TPAs, provider networks, internal teams (Claims, Medical, Compliance, Finance), and external stakeholders

Present insights, findings, and recommendations to management and cross-functional teams

Support training, feedback, and capability building initiatives across TPAs

Reports to : Head of Managed Care Services

Direct Reports : NA

Desired Candidate Profile

Business Knowledge/Technical Skills:

3 - 5 years of experience with provider and / or payer to have a strong knowledge of billing patterns and coding

Strong record of success in data analytics and identification of fraud patterns within claims.

Possess skills to develop creative solutions for medical quality management

Possess skills for feedback mechanism for different stakeholders

A graduate degree, MBA degree or other advance degree is preferred

A nursing degree or Pharmaceutical or Medical degree will be of value however not mandatory.