Analyst -Fraud, Waste & Abuse

Position Purpose :    The Analyst – Fraud, Waste & Abuse (FWA) provides leadership in in the investigation of potential FWA cases; its main goal is aimed at detection and prevention of fraud, waste, and abuse.

Key Responsibilities :

Conduct in-depth investigations of potential FWA cases using monitoring, audits, forensic analysis and interviews; as well as external platforms and guidelines (CMS, state and federal guidelines, etc.)

Analyze large datasets to identify patterns, trends, and anomalies indicative of FWA activity

Develop strategies to mitigate fraud risk and ensuring compliance with regulatory requirements

Maintain process integrity and ensure legitimate claims are processed efficiently

Implement and track corrective action plans

Prevent fraud and educate employees and members on fraud detection and reporting

Document Special Investigations, FWA and Payment Integrity monitoring activities

Collaborate with other departments such as Claims, Medical Management, Internal Audit, Recovery and Legal teams

Support litigation and legal defense by providing evidence to support claim denials or fraud prosecutions

Work with law enforcement and regulators to report fraud cases to I-MEDIC, RPC, AHCA, and other regulators and authorities

Perform monthly audit for excluded / precluded providers

Develop CMS HPMS and AHCA-MPI memos related to sanctioned providers

Develop member complaints received by Member Services for potential FWA

Meet performance goals and metrics established for the position

Performs additional duties and responsibilities as assigned by management

Qualifications :

Minimum of 5 years of FWA, healthcare and / or Medicare Advantage experience

Strong knowledge of Medicare Advantage, CMS and AHCA regulatory requirements

Expertise in FWA, Special Investigations and claims processing

Outstanding research and investigative skills

Proven track record in operations and process improvement

Able to thrive in a complex, high-pressure environment

Bachelor’s degree in Business, Healthcare Administration or related field

High-degree of computer literacy and well versed in Excel

Note :   This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

No Third Party Agencies or Submissions Will Be Accepted.

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

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