Description

Job Description

MedNet Egypt is one of the leading managed care service organizations that cater to healthcare needs. We are looking for skilled Senior Officer – Utilization Management who will be responsible for responsible for hands-on analysis of healthcare utilization and claims data across insurance policies to identify burning cost drivers, abnormal billing patterns, and potential fraud, waste, and abuse (FWA).

Your Job:

• Perform detailed burning cost and loss ratio analysis across policies, products, and provider networks.
• Analyze utilization patterns to identify high-cost, high-utilization, and abnormal billing trends.
• Assess utilization by providers, specialties, diagnoses, and members.
• Monitor high-frequency admissions, visits, investigations, medications, and procedures.
• Track utilization movements and flag unusual cost increases and utilization spikes.
• Identify abnormal provider billing behaviors, including overutilization of diagnostics, procedures, and medications.
• Detect upcoding, unbundling, duplicate billing, excessive LOS, and repeated admissions.
• Prepare analytical case summaries and evidence for escalation to Team Leader and FWA/Medical Audit teams.
• Develop periodic analytical reports and dashboards on burning cost, loss ratio, and utilization variances.
• Conduct provider outlier analysis to identify utilization and cost risks.
• Support development and testing of business rules, flags, triggers, and automated detection tools.
• Ensure accuracy, consistency, and proper documentation of analytical outputs.
• Collaborate cross-functionally with Claims, Approvals, Network, QA, Rule Engine, Production, and FWA teams to support audits and cost containment initiatives.

Your Profile:

• Bachelor’s degree in medical, Paramedical, Insurance, Healthcare Management, or related field
• Medical coding or utilization management certification is an advantage
• 3–5 years’ experience in utilization review, claims analysis, medical audit or healthcare analytics
• Experience in health insurance / TPA environment preferred
• Awareness of local regulatory requirements and UAE market is preferred.
• Strong analytical and critical thinking skills
• Good understanding of medical billing and coding, insurance benefits and utilization norms
• Attention to detail and investigative mindset
• Clear reporting and communication skills