Senior Provider Performance Specialist

About the role

This position is responsible for conducting objective, fair, thorough, unbiased and timely investigations of healthcare fraud and abuse committed against Allianz group or its Payers by members, providers, or other entities while monitoring best of relationships with all parties. The role requires ingenuity to obtain hard‑to‑find information, independent judgment, and strong organizational skills to manage a high volume of cases.

Key responsibilities

• Perform data mining and analysis for providers under investigation.
• Participate in onsite and offsite audits, including claims audits, data trending, and mystery‑shopping campaigns.
• Review files, gather information and collect evidence to detect fraud and abuse on claims.
• Drive savings and cost‑containment strategies and assess methodology for efficient investigations.
• Document all evidence to substantiate meritorious claims, deny unjustified claims, recover inappropriate payments, or recommend actions.
• Support the Medical Provider Performance Manager with administration and monitoring tasks.
• Collaborate with legal, finance, claims operations and external providers, consulting with regulatory authorities when needed.
• Generate periodic dashboards and contribute to specialized procurement projects.

Required profile

• In‑depth knowledge of insurance fraud types, investigation techniques and relevant federal and state regulations.
• Strong interpersonal and relationship‑building skills for interacting with claimants, attorneys, doctors, law enforcement and regulators.
• High integrity, dependability, accountability and ability to handle confidential personal information.
• Proven ability to analyze data, interpret results and adapt to changing work demands.