Fraud, Waste And Abuse Analyst

SUMMARY

The ideal candidate will possess a strong understanding of healthcare regulations and compliance requirements. The primary responsibility of this role is to ensure adherence to regulatory guidelines, detect and prevent fraud, waste, and abuse, and implement strategies to mitigate risks effectively.

DUTIES & RESPONSIBILITIES

FWA Monitoring and Analysis:

• Conduct regular reviews and audits of transactions, claims, and provider/member activities to identify potential instances of fraud, waste, or abuse.

• Analyze data trends and patterns to detect irregularities or suspicious activities.

• Utilize analytical tools and methodologies to assess compliance with regulatory requirements and organizational policies.

Investigation and Reporting:

• Performs data mining and analyses to detect aberrancies/outliers in claims and data to proactively seek out and report FWA.

• Conduct thorough investigations into suspected cases of fraud, waste, or abuse, including gathering evidence, interviewing stakeholders, and documenting findings.

• Prepare detailed reports documenting investigation outcomes, including recommendations for corrective action and risk mitigation strategies.

• Collaborate with relevant departments, such as legal, compliance, and risk management, to address compliance concerns and implement remedial actions.

• Prepares any Health Plan Compliance reports related to FWA

Training and Education:

• Develop and deliver training programs and educational materials to enhance awareness of compliance requirements and FWA prevention strategies among staff and providers.

• Stay updated on emerging trends, technologies, and regulatory changes in the healthcare industry.

• Promotes and contributes to a positive, problem-solving environment.

• Performs other related duties as assigned by management.

REQUIREMENTS

• Associate degree or equivalent preferred.

• Required to have 3+ years of experience working for a Managed Care Organization, specifically with the transportation benefit, or for a transportation broker operating in multiple states.

• Proficient in Microsoft based applications.

• Excellent written and oral communication skills.

• Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm.

• Acute attention to detail.

• Ability to deal effectively with a variety of individuals at all organizational levels.

• Ability to communicate professionally and effectively in person, on the phone, electronically, or through other means to individuals and groups.

• Good judgment with the ability to make timely and sound decisions.

• Professional appearance and demeanor.

• Ability to effectively present information and respond to questions.

Job Type: Full-time