OPEN POSITIONS
FWA Healthcare Investigative Analyst
TX & OK Locations preferred, Remote Considered (Full-Time)
Our Investigative Analysts are dedicated to identifying, investigating and eliminating healthcare fraud and other types of wasteful spend. This position is responsible for using medical coding knowledge and critical thinking to determine if a pattern of billing is suspect. The company uses a customized web-portal tool to access claims data. This role is largely remote and is expected to use Microsoft Teams to communicate and coordinate regularly with other team members. Timely deliverables are of paramount importance.
Primary Responsibilities:
- Investigating and resolving instances of healthcare fraud, waste, and / or abusive billing or payment errors that are provider-based, member-based or claim-based.
- Review claims data and conduct analysis to look for patterns of potential fraud, waste and/or abuse
- Utilizing information from claims data analysis, plan members, and other sources to conduct confidential investigations, document relevant findings and report any suspect billing that could result in an over payment through designated channels
- Conduct data analysis to review claim and case history
- Reviews claims history, medical reviews, provider files, etc. and utilizes data analysis techniques to detect irregularities, billing trends, and financial relationships using state boards, licensing sites, Secretary of State site, etc
Required qualifications:
- Bachelor’s degree or higher
- 3- 5 years work experience related to healthcare fraud investigations
- Strong critical thinking skills
- Experience with manipulating and analyzing large datasets
- Ability to be concise, independent and provide defensible decisions in writing
- Detail oriented with excellent communication skills (oral presentations and written) and interpersonal skills
- Strong PC knowledge and skills, including all Microsoft Office products
- 3-5 years experience with CPT code terminology
Preferred Qualifications:
- Undergraduate degree in the area of criminal justice or related field
- Must have solid ability to accurately document findings in written form
- 3+ years of experience working in the group health business
- An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Pharmacy and/or commercial health insurance)
- Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar
- Certified Coding Specialist
- Experience with computer research
- Experience with data analysis as it relates to healthcare claims adjudication
- Texas and Oklahoma residents preferred.
