- Evaluate claims and determine the most appropriate remedy for preventing fraud, waste, or abuse if applicable.
- Contact external 3rd parties through outbound call or email to verify claim information.
- Negotiate high-cost claims with non-contracted providers.
- Validate accuracy of claim charges and initial processing decisions.
- Coordinate activities across other departments (ex. Clinical, Provider Finance, Customer Service, Claims) and external entities (ex., home plans).
- Determine if claim costs are Usual, Customary, and Reasonable through comparative analysis with historic claims.
- Perform online research to fill in gaps in existing tools and understanding.
- Attempt to obtain written confirmation of falsified claims through independent investigation and recorded interviews/interrogations.
- Perform analysis on historic claims to determine full scope of identified fraudulent activity.
- Track activity and produce reports to measure impact and document actions.
- Other duties as assigned.
- Bachelor's degree or equivalent experience required; advanced degree or certification valued.
- Minimum of 3 years insurance industry experience required; 5-10 preferred.
- Strong attention to detail and problem-solving skills.
- Strong working knowledge of international health insurance claims.
- Knowledge of US Domestic health insurance claims is a plus.
- Previous experience navigating Geo-blue's various claim systems is a significant plus.
- Prior experience identifying or investigating fraud, waste, and abuse is not required, but is highly valued.
- Excellent written and verbal communication skills.
- Strong organizational skills, with the ability to manage multiple competing tasks at the same time.
- Ability to deal with ambiguity and drive for resolution.
- Willingness and ability to learn and apply new skills.
- Multi-lingual strongly preferred.
- Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).
- Flexibility to work in an office and/or at-home, remote office environment.
- Schedule flexibility is occasionally necessary in this position. Individual may be required to attend key business/departmental meetings and/or perform certain business critical job functions outside of normal working hours.
- Physical Demands: Must be able to communicate internally and externally through receiving and responding to auditory and visual methods.
-
Special Investigator
2 weeks ago
AmeriHealth Caritas Newtown Square, United States**Special Investigator - Managed Care**Location: Remote, United StatesPrimary Job Function: ComplianceID**: 34176**Job Brief**This position is a remote position. Must have experience investigating Medicaid / Medicare.Your career starts now. We are looking for the next generation ...
-
Financial Analyst
3 weeks ago
Alivia Analytics Newtown Square, United StatesJob Description · Job DescriptionParticular Details · Job Title · Financial Analyst · Position Level · Highly Motivated Mid-level: Financial Analyst · Industry · Information Technology · Functional Area · Financial Analysis · Total Position · 01 · Job Type · Full Time · Mode · H ...
-
Medicaid Business Analyst
3 weeks ago
Alivia Analytics Newtown Square, United StatesJob Description · Job Description · About role: · We are seeking a highly motivated and experienced Business Analyst to join our dynamic technology team. The ideal candidate will possess a strong understanding of Medicaid operations, healthcare systems, and business processes. Yo ...
-
Medicaid Business Analyst
2 weeks ago
Alivia Analytics Newtown Square, United States3 weeks ago · Be among the first 25 applicants · About role: · We are seeking a highly motivated and experienced Business Analyst to join our dynamic technology team. The ideal candidate will possess a strong understanding of Medicaid operations, healthcare systems, and busines ...
-
Compliance Officer
4 days ago
Bryn Mawr Medical Specialists Association Bryn Mawr, United StatesThe Compliance Officer will oversee the daily operations of the compliance program for our multi-specialty, multi-site medical group. Responsibilities will include development and implementation of policies and procedures that cover all relevant aspects of a medical group complia ...
-
Certified Professional Coder
1 hour ago
Bryn Mawr Medical Specialists Association Bryn Mawr, United StatesJob Description · Job DescriptionFor 55 years the medical experts of Bryn Mawr Medical Specialists Association have been providing personalized care to patients in the Philadelphia region. Our patients have seamless access to 80 highly-trained physicians in 11 specialties and pri ...
-
Certified Professional Coder
1 week ago
Bryn Mawr Medical Specialists Association Bryn Mawr, United StatesJob Description · Job DescriptionFor 55 years the medical experts of Bryn Mawr Medical Specialists Association have been providing personalized care to patients in the Philadelphia region. Our patients have seamless access to 80 highly-trained physicians in 11 specialties and pri ...
-
Financial Risk Analyst
6 days ago
Community Behavioral Health Philadelphia, United States Full timePosition Overview: The Financial Auditor will work collaboratively and independently to evaluate the organization's internal controls, including its governance and accounting processes. These audits will ensure compliance with applicable laws, regulations and CBH policies and pro ...
-
Financial Risk Analyst
3 weeks ago
Community Behavioral Health. Philadelphia, United StatesPosition Overview: The Financial Auditor will work collaboratively and independently to evaluate the organization's internal controls, including its governance and accounting processes. These audits will ensure compliance with applicable laws, regulations and CBH policies and pro ...
-
Deputy Attorney General II-V Environmental Unit
4 weeks ago
DelDOT Wilmington, United StatesIntroduction · Delaware's Attorney General, the State's chief law enforcement officer, has a broad responsibility to combat crime, uphold civil rights, safeguard families, fight fraud, and protect consumers in the First State. In meeting this mission, Attorney General Kathy Jenn ...
-
Medical Director
2 days ago
Community Behavioral Health Philadelphia, United States Full timeThe Medical Director of Quality Management is responsible for the overall medical leadership to the department of Quality Management and the implementation of continuous quality improvement throughout the provider network, as well as within the departments at CBH. He/she provides ...
-
Family Support Partner
2 weeks ago
Community Behavioral Health Philadelphia, United States Full timeThe HFW Family Support Partner (FSP) is/was the caregiver of a youth who was personally involved in a child-serving system, allowing the FSP to have a unique understanding of the families they serve. The FSP assists assigned families in identifying, prioritizing and working towar ...
-
Medical Director for Adult Services
1 week ago
Community Behavioral Health. Philadelphia, United StatesThe Medical Director of Adult Services is responsible for providing administrative oversight and supervision of the CBH physician advisors conducting utilization review for our adult members. The position provides leadership in the development and implementation of clinical/medic ...
-
Process Engineer
5 days ago
Oxy Oldmans Township, United StatesProcess Engineer Description Contribute. Grow. , action-oriented, safety driven chemical manufacturing company continually striving to be the best in the business while staying focused on environmental protection. The secret to our success has and will continue to be our people. ...
-
Forensic Auditor
4 weeks ago
The School District Of Philadelphia Philadelphia, United StatesNOTE - In order to be considered for this position, you MUST submit a cover letter that is specific to this role. · This is a full-time, Non-Represented role. The salary grade for this posting is 4024. The salary range is $53,834 to $72,496 . Please note that the final salary wi ...
-
Financial Investigator III
2 days ago
Independence Blue Cross Philadelphia, United StatesBring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve. · JOB DESCRIPTION fo ...
-
Financial Risk Manager
4 days ago
Community Behavioral Health. Philadelphia, PA, United States Full timePosition Overview: The Financial Auditor will work collaboratively and independently to evaluate the organization's internal controls, including its governance and accounting processes. These audits will ensure compliance with applicable laws, regulations and CBH policies and pro ...
-
Financial Risk Analyst
5 days ago
Community Behavioral Health. Philadelphia, United StatesJob Description · Position Overview: The Financial Auditor will work collaboratively and independently to evaluate the organization's internal controls, including its governance and accounting processes. These audits will ensure compliance with applicable laws, regulations and CB ...
-
Financial Risk Analyst
4 weeks ago
Community Behavioral Health. Philadelphia, United StatesJob Description · Job DescriptionPosition Overview: The Financial Auditor will work collaboratively and independently to evaluate the organization's internal controls, including its governance and accounting processes. These audits will ensure compliance with applicable laws, reg ...
-
Pharmacy Manager
2 weeks ago
Nuvem Philadelphia, United StatesNuvem's Pharmacy Management Team is looking for a compassionate, patient centric Pharmacist to manage and grow our pharmacy presence. Our goal is to make you feel empowered in the role that you play when managing your pharmacy, personnel, client relationships/clinic support and p ...
Fraud Waste - King of Prussia, United States - Worldwide Insurance Services
Description
Job Description
Job DescriptionWe are hiring for a Fraud, Waste, and Abuse Specialist to join the team Multilingual abilities are strongly preferred due to the nature of this role, but not required. The Fraud, Waste, and Abuse (FWA) Specialist is responsible for the day-to-day execution of our enhanced claim control strategies. The Specialist is on the front line of Geo-blue's efforts to reduce unnecessary medical spend and make healthcare more affordable for everyone. The primary responsibility will be to evaluate claim submissions for evidence of fraud, waste, or abuse using an ever-increasing set of tools and techniques, none more important than good judgement and creative problem solving.
Responsibilities:
Requirements:
Working Conditions:
Internal Pay Grade: 8
The starting pay for this role is $50,921 to $63,651 based on skill level and experience in a similar role.
This job description reflects management's assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned.