The Financial Analyst - Fraud, Waste and Abuse (FWA) is responsible for identifying, investigating and preventing fraudulent, wasteful and abusive activities related to healthcare claims, insurance, government programs, or organizational operations. This role uses data analysis, investigative techniques, and regulatory knowledge to detect suspicious patterns, minimize financial losses and ensure compliance with applicable laws and company policies.
Key Responsibilities:Reporting & Analytics Support- Analyze medical, pharmacy, provider, and member-level claims data to identify potential FWA, overutilization, unusual billing patterns
- Perform data mining, auditing, trend analysis, outlier detection, and root-cause analysis across providers, members, CPT codes, diagnosis codes, DRG codes, and claim types.
- Generate and prioritize investigative leads
Recovery and Payment Integrity Activities- Support pre-payment and post-payment review activities
- Recommend enhancements to claim edit rules and controls to prevent future improper payments
Reporting and Monitoring- Document models, provide investigative summaries and recommendations for review by FWA, Finance, Compliance, Medical Management, and other leadership.
- Produce FWA dashboard, and reports on savings and recoveries, trends and emerging risks, provider and member monitoring, etc.
Documentation- Support FWA program reporting, audit responses, policy/procedure development, and operational documentation
Other- Maintain confidentiality of sensitive information and investigative findings
- Meet performance goals as established for the position
- Perform additional duties and responsibilities as assigned by management
The above statement reflects the general duties considered necessary to describe the principal functions of the job identified and shall not be considered as a detailed description of all work requirement inherent to the position.
Qualifications:- Bachelor’s degree
- Three-year experience in healthcare and/or Medicare Advantage plans
- Experience with healthcare claims analysis, large data sets and claim analytics
- Ability to manage multiple investigations simultaneously
- Able to meet deadlines, multi-task and thrive in high-pressure environment
- Excellent oral and written communication
- Proficiency with MS office with advanced skills in Excel and SQL
- Experience with PowerBI and developing dashboards
- Ability to work independently and collaboratively in a team environment
No Third Party Agencies or Submissions Will Be Accepted. Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.
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