Job Description

1. Job Description

Job Title: Internal Audit Officer – Claims & Customer Care
Department: Internal Audit
Location: Amanah Insurance
Reports To: CEO

1. Job Summary

The Internal Audit Officer – Claims & Customer Care supports the review of medical claims and customer care operations to strengthen compliance, internal controls, service quality, and operational efficiency. The role helps assess whether claims and customer service activities are processed accurately, consistently, and in line with policy terms, internal procedures, and service standards. The position also supports the identification of fraud risks, service gaps, control weaknesses, and opportunities for process improvement.

1. Duties and Responsibilities

• Review pre-authorization and post-authorization claims to ensure compliance with policy benefits, exclusions, limits, and underwriting terms.
• Examine provider invoices, supporting documents, and agreed tariffs to identify overpayments, duplicate claims, billing errors, and claims leakage.
• Support audits of hospitals, pharmacies, laboratories, and other service providers to assess compliance with contracts, service standards, and billing practices.
• Review customer inquiries, complaints, and pre-authorization cases to assess adherence to service standards, turnaround times, and escalation procedures.
• Evaluate the effectiveness of internal controls, approval processes, documentation standards, and compliance with internal policies and procedures.
• Assist in identifying suspicious claims, unusual utilization patterns, provider abuse, and other fraud indicators, and escalate concerns appropriately.

Experiences and Qualifications

• Bachelor’s degree in medicine, Nursing, Pharmacy, Public Health, Health Administration, or a related field.
• Training or practical knowledge in Microsoft Excel and basic data analysis is required.
• Additional training in internal audit, compliance, insurance operations, or fraud review is an advantage.

Experience

• At least 1–2 years of relevant work experience in medical claims, health insurance operations, provider management, customer care, compliance, or internal audit.
• Experience reviewing claims files, medical invoices, pre-authorizations, customer complaints, or operational records is preferred.
• Experience working with hospitals, pharmacies, laboratories, or other healthcare providers will be an added advantage.
• Exposure to identifying errors, exceptions, unusual trends, or control gaps in claims or service processes is desirable.

Skills and Competencies

• Good understanding of medical claims processes and healthcare service operations.
• Strong attention to detail and ability to review documents and transactions accurately.
• Good analytical, reporting, and problem-solving skills.
• Ability to use Excel to review, organize, and analyse data.
• Good written and verbal communication skills, including report writing.
• Ability to handle confidential information with professionalism and integrity.

Success Measures

• Claims and customer care reviews are completed accurately, consistently, and on time.
• Key control gaps, compliance issues, and service weaknesses are identified and reported clearly.
• Audit findings are evidence-based, practical, and support timely management action.
• Fraud indicators, unusual claims trends, and provider concerns are escalated appropriately.
• Recommendations contribute to improved controls, stronger compliance, better service quality, and reduced financial leakage.

Skills Required

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