SIU Fraud Analytics Specialist - Wheeling, WV

Job summary

The SIU Fraud Analytics Specialist is a key member of a team dedicated to the prevention, detection, investigation, and reporting of healthcare fraud, waste, and abuse (FWA), program integrity initiatives, and the recovery of overpayments in a multi-payer environment.

Responsibilities

• Monitoring/attending to various FWA allegation reporting tools such as: THP fraud hotline, THP FWA Web Portal, SIU/QI Form Submissions.
• Gathering preliminary information on all incoming allegation referrals and preparing them for SIU review, to ensure timely and proper assignment or disposition.
• Entering cases into the case management and tracking system and Analyzing healthcare claims data and other relevant information reactively, in response to allegations of FWA, to ascertain potential exposure.
• Leveraging analytic tools to provide in-depth data analysis in support of fraud investigations and payment integrity activities;
• Conducting strategic analysis of healthcare claims data from initial data scoping through transformation and validation, and conveying results in verbal, written, and visual formats;
• Analyzing healthcare claims data and other relevant information reactively, in response to allegations of FWA, and proactively, to identify trends and patterns indicative of FWA;
• Utilizing fraud detection software and large data sets to identify outliers and inform decision-making related to FWA investigations and the identification and recovery of overpayments;
• Obtaining, cleaning, normalizing, and validating healthcare claims data for the purposes of supporting FWA investigations and informing investigative and recovery decisions;
• Drafting clear and concise, yet appropriately detailed reports of findings which may include recommendations related to case disposition, corrective actions, and/or process improvements;
• Analyzing and synthesizing information from multiple sources including claims data, contracts, enrollment data, provider manuals, educational materials, bulletins, and state and federal regulations, to determine impact on claims payment as it relates to SIU cases or leads;
• Responding to requests for information from various sources, including Medicaid, I-MEDIC, MFCU, and the WV OIC;
• Expertise in the use of fraud detection software and case tracking system;
• Creating and delivering training on databases, analytics software, and other relevant systems and techniques;
• Identifying and recommending process improvements to reduce FWA;
• Tracking, trending, and reporting identified metrics, including dashboard reporting;
• Maintaining technical knowledge and skills by attending professional conferences and trainings, obtaining or retaining professional certification(s), and pursuing constant learning through membership in relevant professional organizations;
• Investigating matters of payment integrity as assigned by the FWA Data Analytics Manager.

Job description