Senior Fraud Analyst

Job Description:

Position Summary:
The Sr. Fraud Analyst will be responsible for developing and maintaining fraud investigation strategies and managing outsourced vendors in all areas pertaining to fraud, waste, and abuse. This position requires a well developed understanding of the health insurance / health care industry, and in-depth understanding of health care data and the methods of data analysis.

General Responsibilities:

  • Manage all outsourced vendor relationships pertaining to fraud, waste, and abuse detection; medical record review; and case development.
  • Maintain aggressive project plan for the identification of overpayments from multiple sources and communicate to all affected areas of the business including claims, compliance, provider relations, call center, and management.
  • Prepare case documentation to present to the Fraud, Waste and Abuse steering committee.
  • Report operational impacts and productivity and financial impacts on a weekly basis.

    Required Education & Work Experience:
  • Bachelor's degree in criminal justice, health science, administration or a related field.
  • Education requirements may be substituted if the applicant has 5 or more years of related benefit integrity experience.
  • A minimum of 3 years supervisory experience in the general area of benefit integrity investigation.

    Required Knowledge, Skills, and Abilities:
  • Ability to interface with multiple users across the organization and effectively project manage vendor relationships.
  • Ability to work in a rapidly changing and growth oriented environment with regularly changing priorities and developing opportunities.
  • Ability to perform research and draw conclusions
  • Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the health plan.
  • Ability to organize a case file, accurately and thoroughly document all steps taken
  • Ability to compose correspondence, reports and referral summary letters
  • Ability to train provider relations staff and educate providers, provider associations, and other staff on program safeguard matters
  • Ability to interpret laws and regulations
  • Ability to handle confidential material
  • Ability to report work activity on a timely basis
  • Ability to work independently and as a member of a team to deliver high quality work
  • Strong analytical and problem solving skills and abilities.
  • Demonstrate strong communication (both verbal and written), and customer service skills, and exchange information with others clearly and concisely.
  • Take ownership of each project from start to finish and follow-up with management on project status.
  • Excellent communication and interpersonal skills.

    We are proud to be an EEO/AA employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse testing.



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