Support the detection, investigation and prevention of fraud, abuse, waste and irregularities in the use of health benefits, through data analysis, claims auditing and case document management. Contribute to the reduction of losses and improvement of internal controls.

2. PRIMARY DUTIES

a)    Data discovery and analysis:

• Analyze alerts from fraud detection systems, including biometric device transactions and claims processing data.
• Cross-reference alerts with claims histories, pre-authorizations, and member and provider data to identify cases that require investigation.
• Identify suspicious patterns, duplications, excessive frequencies, and outliers.

b)    Claims audit:

• Review invoices, prescriptions, clinical reports, diagnoses, procedures, codes and tariffs.
• Identify services not provided, duplicate or advance billing, excessive quantities, undue prices and services already included in packages.
• Support desk audits and visits to providers to verify billed services and compliance with applicable rules.

c)    Investigation and case management:

• Register and monitor cases on the investigation management platform, keeping facts, actors, evidence and decisions duly documented.
• Support investigations involving members, contractors, intermediaries, collaborators and possible situations of collusion.
• Prepare requests for clarification, analyze responses and refer complex cases to the Senior Manager.
• Ensure the integrity, traceability and confidentiality of evidence.

d)    Reporting and prevention:

•  Prepare research reports with results, evidence, values involved and recommendations.
•  Support the calculation of undue amounts, recoveries and avoided losses, as well as the preparation of periodic indicators.
• Identify control failures and propose improvements in detection rules and internal processes.
•  Monitor the approved corrective measures, in conjunction with the areas responsible.

e)    Collaboration and compliance:

• Collaborate with the Clinical, Claims, Pre-Authorizations, Provider Management, Finance and Information Technology areas.
• Comply with internal policies, legal requirements and data protection and confidentiality rules.
• Perform other forensic audit-related tasks assigned by the Senior Manager.

3.    JOB REQUIREMENTS:

3.1.  Experience & Qualification:

• At least 1–2 years of experience in a corporate environment, experience in the healthcare or insurance sector is an advantage.
• 12^th grade completed, diploma in Health, Nursing, Pharmacy, Biomedical Sciences or a related area is preferred.
• Knowledge of clinical terminology, diagnostic codes and procedures, tariffs and billing of health services.
• Knowledge of auditing, investigating or preventing fraud is an advantage.
•  Mastery of office tools, especially Excel, and ease of use of data analysis and case management systems.
• Good oral and written communication in Portuguese and knowledge of English.

3.2. Skills & attributes:

• Analytical skills.
• Attention to detail.
• Identification of patterns.
• Organization.
• Report preparation.
•  Case follow-up.
• Integrity.
• Impartiality.
• Discretion.
•  Accountability.
• Teamwork.

What We Offer:

• A collaborative work environment.
• Opportunities for professional growth.
• 100% Subsidized Medical Aid.

📩 To apply, send your resume cv@mediplusmz.com with the subject line ” your name – Forensic & Audit Agent”

📌 Only shortlisted candidates will be contacted.