Senior Analyst, Fraud, Waste and Abuse Investigation

Responsibilities

• Leverage analytical skills to review claims data and identify patterns of suspected potential FWA.
• Assist in the triage, preliminary investigation of all internal and external FWA complaints.
• Refer all cases of suspected FWA to regulatory agencies within required timeframes.
• Assist in the monitoring of the FWA hotline and FWA shared email box.
• Participate in the prepayment review process including detailed review of medical records against claims data.

Requirements

• 3-5 years’ work experience
• CPC or equivalent coding certification
• Working knowledge of standard industry coding guidelines such as CPT, HCPCs, ICD-10
• Experience reviewing medical records to ensure that documentation matches services billed
• Experience reviewing detailed data to interpret claims data

Core Competencies

Demonstrates expertise in analyzing claims data to identify patterns of suspected fraud, waste, and abuse (FWA), while ensuring compliance with industry coding guidelines. Proficient in reviewing medical records and interpreting claims data to support investigations and regulatory referrals.