Accountabilities and activities
- Conduct comprehensive reviews to identify operational deficiencies and potential FWA risks, driving enhancements in processes and workflow streamlining to increase operational efficiency and integrity.
- Stay updated on legislation and regulatory changes related to FWA in insurance claims, ensuring that all practices are compliant and aligned with industry standards and legal requirements.
- Ensure company goals are met while maintaining strict adherence to legal and corporate standards, particularly in relation to FWA prevention and detection.
- Maintain open communication channels with key departments—Underwriting, Customer Services, Provider Relationship, Complaint Management, Finance, People, IT, Legal, Compliance and Risk and Control—to foster collaboration in identifying and mitigating FWA risks.
- Identify opportunities for enhanced control through management reports and data analytics, incorporating FWA indicators and trends to support proactive decision-making.
- Provide tactical leadership to the team in delivering the Claims strategy, embedding FWA awareness and accountability into daily operations.
- Prepare for and participate in audits and compliance reviews, ensuring operational procedures are robust against FWA and compliant with regulatory expectations.
- Regularly analysis of FWA workflows leveraging emerging technologies and data-driven insights to enhance efficiency and reduce exposure to FWA.
- Lead and collaborate on strategic initiatives such as product implementation, digitalization, compliance, and control, integrating FWA safeguards into project planning and execution.
- Keep the Head of Claims Excellence informed of developments in claims and case management, especially those impacting FWA trends, regulatory shifts, and operational vulnerabilities.
- Champion a culture of integrity and vigilance, promoting awareness and training on FWA across the claims organization to strengthen internal controls and ethical standards.
- Serve as the Subject Matter Expert (SME) for all projects related to Claims and the Claims Excellence Team, acting as a liaison with the IT department to define user requirements and lead User Acceptance Testing (UAT) for successful deployment of new systems and system enhancements of existing platforms, with embedded FWA controls.
- Manage the FWA/Claims/Audit Rules Master List, ensuring timely updates and alignment with evolving fraud trends, regulatory requirements, and operational needs.
- Act as a Fraud Ambassador, actively participating in team meetings to share insights, promote fraud awareness, and recommend improvements to claims and fraud operations that minimize disruption to customer experience.
- Develop and Initiate the FWA Framework to lead the FWA team in handling of fraud alerts and take swift, appropriate action to protect both customers and the organization, ensuring timely escalation and resolution.
- Reconcile fraud dispute claims with identified fraudulent transactions, ensuring accuracy and completeness in reporting and resolution.
To be successful in the position, you should have
- Bachelor’s degree or qualifications in Business Administration, Finance/Accounting, Insurance or equivalent
- Minimum of 10 years’ solid experience within the insurance industry with a specialized focus on Fraud, Waste, and Abuse (FWA) management. Proven track record in medical insurance, claims fraud detection, and project management.
- Leadership Experience: Over 5 years of people management experience, demonstrating strong leadership, team development, and cross-functional collaboration capabilities.
- Regulatory & Medical Knowledge: Deep understanding of insurance and healthcare regulations, complemented by solid medical knowledge essential for fraud analysis in insurance solution environments.
- Financial Crime & Risk Management: Advanced expertise in financial crime investigation, particularly cyber fraud threats, and comprehensive knowledge of risk management principles, policy impacts, and mitigation strategies.
- Technical Proficiency: Highly skilled in Microsoft Office Suite (Word, Excel, PowerPoint, Access) and adept in relational database management. Strong analytical capabilities for data interpretation and system analysis.
- Claims System Analysis: Exceptional analytical skills to identify vulnerabilities in claims systems and the medical insurance landscape. Capable of diagnosing root causes and proposing resource-conscious workflow enhancements.
- Investigative & Communication Skills: Experienced in conducting thorough investigations and interviews related to fraudulent activities. Possesses excellent verbal and written communication skills for drafting reports, statements, and engaging stakeholders across all organizational levels.
- Attention to Detail: Meticulous in handling sensitive information, ensuring accuracy and completeness in case investigations.
- Collaborative & Resilient: Effective in team-oriented environments, with a strong ability to collaborate across departments. Demonstrates resilience and thrives under pressure.
- Data Analysis & Decision-Making: Proficient in analyzing and synthesizing large datasets. Capable of making complex investigative decisions independently and proactively delivering actionable solutions.
- Language Proficiency: Fluent in English and Cantonese, both written and spoken.
Bupa offers 5 days’ work per week and comprehensive remuneration packages including base salary, study assistance plan, company pension plan, life and medical benefit, dental benefit, annual leave, examination leave, etc.
Bupa is an equal opportunity employer and welcomes applications from qualified candidates. Information provided will be treated in strict confidence and only be used for consideration of application with Bupa.
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