Medical Provider Performance Executive

About the role

The Medical Provider Performance Executive leads objective, fair and timely investigations of healthcare providers for fraud, waste and abuse affecting Allianz Group and its payers. The role requires strong analytical abilities, creativity in obtaining hard‑to‑find information, and the capacity to work independently while managing a high volume of cases.

Key responsibilities

• Detect and prevent fraud, waste and abuse by medical providers across assigned regions.
• Perform data mining and advanced data analysis to support investigations.
• Review claims files, gather evidence, and document findings to substantiate or deny claims.
• Participate in onsite audits, in‑house claims audits and mystery‑shopping campaigns.
• Support the Medical Provider Performance Manager with administrative and strategic tasks.
• Prepare comprehensive investigative reports and dashboards.
• Collaborate with legal, finance, claims operations and external stakeholders.
• Consult with regulatory authorities when legal action is required.
• Utilise AI, machine learning, data analytics and cloud‑based tools while ensuring data governance and security.

Required profile

• Clinical or para‑medical background with strong medical knowledge.
• Proficiency in medical coding systems (ICD, CPT, HCPCS).
• Understanding of claims adjudication, payer rules and policy exclusions.
• Experience in fraud, waste and abuse detection and root‑cause analysis.
• Excellent analytical and investigative skills.

Required skills

• ICD coding
• CPT coding
• HCPCS coding
• Data mining
• Data analysis
• Machine learning
• Cloud‑based analytics tools