Job Description

Responsibilities

• Identify and conduct investigations into known or suspected FWA with high autonomy
• Develop documentation to substantiate findings including formal reports graphs audit logs and other supporting documentation.
• Perform root cause analysis to inform future algorithmic identification of similar claims or cases and associated savings (i.e. help move identified case types from pay-and-chase to preventive edits and pre-payment activity)
• Participate in the development and presentation of FWA-related education for assigned Customers
• Perform coding reviews for flagged claims to support Coding team (if applicable).

• Minimum of 2 years of experience in healthcare claims analysis auditing payment integrity or a related field.
• Bachelors degree in Criminal Justice or a related field or at least 3 years of insurance claims investigation experience or professional investigation experience with law enforcement agencies.

• Knowledge of applicable fraud statutes and regulations and of federal guidelines on recoupments and other anti-FWA activity
• Experience handling confidential information and following policies rules and regulations
• Experience with commercial Medicare or Medicaid claims

• Strong analytical and problem-solving skills with attention to detail and accuracy
• Excellent communication skills both written and verbal for effective collaboration with internal teams and external providers
• Proficiency in Microsoft Office particularly Excel and familiarity with claims processing or audit software
• Certified Fraud Examiner (CFE) Accredited Healthcare Fraud Investigator (AHFI) Certified AML (Anti-Money Laundering) and Fraud Professional (CAFP) or similar is preferred
• Certified Professional Coder (CPC) or similar is preferred

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