Claims Fraud Manager

BEST DOCTORS INSURANCE SERVICES LLC•Miami, FL

About The Position

The Claims FWA Manager is responsible for leading initiatives to detect, prevent, and mitigate fraud, waste, and abuse within claims operations, with a strong focus on cost containment and operational efficiency. Reporting directly to the COO, this role plays a critical part in safeguarding financial integrity, optimizing claims processes, and deploying advanced tools and analytics to reduce exposure to fraudulent activities while maintaining a positive customer experience.

Requirements

Bachelor’s degree in Business Administration, Finance, Insurance, or related field.
Minimum 8–10 years in health or medical insurance claims operations with a strong focus on fraud detection and cost containment.
Proven track record in managing FWA programs and leading investigative teams.
Expertise in claims systems, fraud detection platforms, and data analytics tools.
Advanced Microsoft Excel and familiarity with SQL or similar query languages.
Strong analytical and investigative skills with attention to detail.
Excellent communication and stakeholder engagement abilities.
Ability to lead projects and thrive under pressure in a fast-paced environment.
Bilingual (Spanish and English) required

Nice To Haves

International Health Insurer experience preferred
Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or equivalent.
Portuguese preferred.

Responsibilities

Claims Cost Containment & Risk Mitigation:
Develop and implement strategies to reduce fraudulent and abusive claims, minimizing financial leakage.
Analyze claims data to identify patterns, anomalies, and high-risk areas for cost containment.
Investigations & Analytics:
Lead investigations into suspicious claims and provider activities, ensuring timely resolution and recovery.
Coordinate reviews with Risk and Legal areas, to ensure accurate fraud assessments.
Utilize predictive modeling, data mining, and fraud detection tools to enhance claims oversight.
IT Collaboration & Tool Deployment:
Partner with IT teams to define requirements for fraud detection and claims analytics tools.
Lead User Acceptance Testing (UAT) and oversee deployment of new systems and enhancements with embedded FWA controls.
Drive automation and digitalization initiatives to improve fraud detection and claims efficiency.
Strategic Leadership & Cross-Functional Collaboration:
Work closely with Provider Relations, IT, Finance, Underwriting, Legal and Customer Service to embed FWA controls into claims workflows.
Act as a key liaison for strategic projects impacting claims operations and fraud prevention.
Provide regular updates to the COO on fraud trends, cost containment results, and technology initiatives.
Reporting & Continuous Improvement:
Develop dashboards and management reports highlighting fraud trends, cost savings, and operational improvements.
Recommend process enhancements based on data-driven insights and emerging fraud schemes.
Training & Awareness:
Deliver training programs to claims teams on fraud detection techniques and cost containment strategies.
Promote a culture of vigilance and accountability across claims operations.