Medical Provider Performance Executive

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 whilst 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 detection 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, and 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 audits, and mystery shopping campaigns

Support the Medical Provider Performance Manager with all administration and support tasks to drive fraud detection and prevention

Assess the scope and determine the methodology needed to carry out an efficient investigation

Prepare comprehensive investigative reports and analysis

Collaborate and communicate internally with associated departments, i.e. legal, finance, claims operations, as well as external clients and providers

Consult with legal and regulatory authorities for cases that may involve legal action

Manage and ensure generation of periodic dashboards

Participate in specialized projects and assignments related to procurement, as required

Maintain provider relationships in coordination with the MPM team

Use judgment, diplomacy, and confidentiality with respect to the complete procurement process, ensuring integrity

Preserve the reputation of the company, beneficiaries, payers, and all other parties involved

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 paramedical background

Coding expertise - ICD, CPT, HCPCS proficiency

Knowledge of claims adjudication - policies, benefits, exclusions, payer rules

Fraud, waste, and 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 and 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's 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.