Job Overview

This position is responsible for conducting objective, fair, thorough, unbiased and timely investigations of healthcare providers for fraud, waste and abuse committed against Allianz group or its Payers by members, providers, or other entities whist monitoring best of relationships with all parties.

The position requires ingenuity and creativity to obtain case information not readily available, along with the ability to work independently with minimum supervision. Good organizational skills are needed to manage a high volume of assigned cases as well as the regular exercise of independent judgment and initiative to investigate allegations.

The investigator must have the analytical ability necessary to review, interpret and evaluate relevant information essential in resolving sensitive and complex investigations.

Key Responsibilities:

• Fraud Abuse and Waste detections and prevention from Medical providers for allocated regions/countries
• Data mining and data analysis are required for conducting investigations on provider claims.
• Support and drive the savings target strategy as set by the Global head of MPM
• Review files, gather information, collect evidence to detect fraud and abuse on claims
• Document all evidence obtained in the investigation in order to substantiate meritorious claims, to deny unjustified claims, to recover inappropriate payments or to recommend action against responsible parties
• Participate in onsite Audits, in-house claims audit and Mystery shopping campaigns
• Support the Medical Provider Performance Manager with all administration and support tasks to drive Fraud detections and prevention.
• Assesses the scope and determine the methodology needed to carry out an efficient investigation.
• Prepare comprehensive investigative reports and analysis
• Collaborates and communicates internally with associated department's ie legal, finance, claims operations as well as external clients and Providers.
• Consults with legal and regulatory authorities for cases that may involve legal action.
• Manages and ensures generation of periodic dashboards
• Participates in specialized projects and assignments related to procurement, as required.
• Maintains provider relationship in coordination with MPM team
• Uses judgment, diplomacy and confidentiality with respect to the complete procurement process, ensuring integrity.
• Preserves the reputation of company, beneficiaries, payers and all other parties Involved. Participates in specialized projects and assignments related to procurement,
• Work effectively with AI, machine learning, data analytics, and cloud-based tools, adhering to high standards of data governance, security, and ethical use.

Key Requirements:

• Clinical knowledge - Medical or Para medical background
• Coding expertise - ICD, CPT, HCPCS proficiency
• Claims adjudication knowledge - Policies, benefits, exclusions, payer rules
• Fraud, Waste & Abuse (FWA) detection - Identifying anomalies, upcoding, unnecessary care
• Analytical skills - Data review, trend analysis, root-cause identification
• Regulatory awareness - Compliance with local regulations, payer guidelines
• Attention to detail - Accuracy in audit reviews and documentation
• Audit methodology - Sampling, retrospective & concurrent audit techniques
• Negotiation and Communication skills - Clear reporting, provider engagement, negotiation and escalation handling
• Systems proficiency - Claims systems, audit tools, Excel/data tools

Allianz Group is one of the most trusted insurance and asset management companies in the world. Caring for our employees, their ambitions, dreams and challenges is what makes us a unique employer. We are united by a shared commitment: to put our customers first and at the center of everything we do. Their needs inspire our thinking and guide our actions. Together, we can build an environment where everyone feels empowered and confident to explore, grow and shape a better future - for our customers and for the world around us.

At Allianz, we stand for unity: we believe that a united world is a more prosperous world, and we are dedicated to consistently advocating for equal opportunities for all. The foundation for this is our inclusive workplace, where people and performance both matter, and where integrity, fairness, inclusion and trust are at the heart of our culture. We therefore welcome applications regardless of race, ethnicity or cultural background, age, gender, nationality, religion, social class, disability or sexual orientation, or any other characteristics protected under applicable local laws and regulations.

Great to have you on board. Let's care for tomorrow.

Note: Having different strengths, experiences, perspectives and approaches is an integral part of Allianz' company culture. One means to achieve this is a regular rotation of Allianz employees across functions, Allianz entities and geographies. Therefore, Allianz expects from its employees a general openness and a high motivation to regularly change positions and collect experiences across Allianz Group.