Analyst - Fraud, Waste & Abuse
Coral Gables, FL
Full Time
Experienced
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:
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.
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
- 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
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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