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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).

Requirements

• Minimum of 2 years of experience in healthcare claims analysis, auditing, payment integrity, or a related field.
• Bachelor's 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