As a Medical Auditor at ProtectHealth, you will play a critical role in safeguarding the integrity of Malaysia’s national healthcare programs. You will ensure that hospitals, clinics, and labs deliver high-quality, ethical, and compliant care, while detecting fraud, waste, and abuse (FWA) to protect public healthcare funds and improve patient outcomes.

Responsibilities:

1. Conduct structured audits on healthcare providers participating in national health programs such as PeKa B40, SPM, and HSOP to evaluate service delivery and compliance with ProtectHealth’s standards, policies, and scheme-specific guidelines.
2. Review medical claims, treatment documentation, and overall provider conduct to ensure compliance with clinical & operational expectations.
3. Identify potential non-compliance, fraudulent activities, or service inconsistencies. Recommend corrective actions and preventive measures to uphold integrity and accountability.
4. Document audit findings, provide clear recommendations, and present reports to internal stakeholders for decision-making and continuous improvement initiatives.
5. Work closely with relevant departments to address issues of non-compliance, support provider development efforts, and improve service quality under various healthcare schemes.
6. Assist in enhancing internal audit tools, methodologies, and processes tailored to healthcare service evaluation.
7. Perform other related duties as required and assigned by the supervisor or management. 

Requirements: 

1. Bachelor’s Degree in Medicine, Pharmacy, Nursing, Health Economist or related field.
2. Candidates with minimum 2-5 years experience in healthcare auditing, claims management, clinical governance or fraud detection in the healthcare/insurance sector are encouraged to apply.
3. Strong understanding of healthcare quality standards, clinical documentation, and service delivery frameworks.
4. Analytical, detail-oriented, and able to handle sensitive information with confidentiality.
5. Excellent communication, report writing, and stakeholder engagement skills.
6. Willingness to travel frequently (up to 50% nationwide, with occasional overseas assignment) to conduct audits and collaborate with healthcare provides onsite.