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.
- 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
