Project Manager – Insurance Claims & FWA

The Project Manager – FWA is responsible for :

- The end-to-end planning, coordination, execution, and governance of the company's Fraud, Waste & Abuse initiatives across the health insurance value chain.

- Drives the implementation of the Group-wide FWA Framework, Policy, and Solution—including AI-enabled FWA detection tooling (e.g., ReyID, Rey.ID, DICE, OCR modernization, Gemini rules/ML), governance controls, and MVP roadmaps (MVP 1–3)—in alignment with Group Health FWA Standards, POJK regulatory expectations

- Ensures FWA deliverables meet quality standards, timelines, budget constraints, claim savings targets, and loss ratio control objectives, while supporting the company's mandate to"deter, prevent, detect, report and remedy fraud in insurance" under the Group Fraud, Waste and Abuse Policy (GFWAP).

Role:

- Develop detailed project plans, timelines, resource allocation, budgets, and ACR (Approval Committee Request) submissions for FWA MVPs and new initiatives.

- Manage the full project lifecycle (Initiation ? Planning ? Execution ? Monitoring ? Closing) per the company SOP Project Governance & Lifecycle

- Track program performance using KPIs: claim savings, claim avoidance, investigation success rate, decline rate, and medical cost impact (cashless vs reimbursement).

- Prepare and present progress updates, risk logs, MoMs, and executive summaries to Health Performance Council, ExCo, and Group Health FWA CoE meetings.

- Manage relationships with external vendors, internal teams, and Group stakeholders to ensure delivery commitments, issue resolution, and successful implementation outcomes.

Qualification:

1. Bachelor's degree from a reputable university (Insurance, Business, Healthcare Management, Data Analytics, Actuarial, or related field); Master's preferred.

2. Professional certifications preferred: PMP, Six Sigma, Certified Fraud Examiner (CFE), or equivalent.

Experience

1. Minimum 5–8 years in project/program management, with 3+ years in health insurance, claims operations, payment integrity, or FWA/anti-fraud programs.

2. Proven experience implementing FWA detection tools, claims analytics platforms, or AI/ML solutions in an insurance or healthcare context.

3. Experience managing cross-functional implementation across Claims, UW, Provider Management, Agency, IT, and external vendors.

4. Familiarity with Medicare/Medicaid, BPJS, POJK regulations, and Group compliance frameworks is a strong advantage.

Knowledge & Skills

1. Have understanding of FWA, health insurance claims lifecycle, provider billing practices, and medical loss ratio drivers.

2. Strong capabilities in claims data analysis, anomaly detection, rule-based detection, and ML/statistical methods.

3. Excellent stakeholder coordination, change management, and executive communication skills.

Proficiency in project management tools (JIRA, Smartsheet, ClickUp, MS Project) and MS Office (Word, Excel, PowerPoint).

4. Fluent in English and Bahasa Indonesia (business/legal writing).

5. Analytical thinking, attention to detail, and ability to translate business FWA hypotheses into analytical checks and operational workflows.