Job Description

Fraud, Waste and Abuse Investigator

Elite Technical is seeking a Fraud, Waste and Abuse Investigator to join our clients Utilization Management Department. This position actually identifies and investigates our clients fraudulent claims. This position is responsible for coordinating internal and external resources to enhance the detection and deterrence of fraudulent or abusive activities perpetrated against our client and its members. This is completed through comprehensive in depth review of suspected claims fraud referrals received from outside sources (e.g., providers or members) or, internally, by utilizing investigative guidelines from the Office of Personnel Management (OPM) or the Office of Inspector General (OIG) to investigate active claims.

The selected candidate is responsible for efficiently and accurately assessing referrals submitted for investigation
to determine if there is merit in the allegation and a matter that should be addressed. A comprehensive review will be conducted to identify highly suspect billing behaviors and trends, and potential overpayments, ultimately leading to formulation of specific investigative next steps. The finished product should be designed in a manner that allows the investigator to fully understand what actions should be taken to mitigate patient harm and financial risk. Similar action will be taken when suspicion arises by means of internal claims investigation.

This position is a permanent/direct hire opportunity with our client, a Federal Health Plan in the BWI/Maryland area. This position is a hybrid opportunity once training has completed.

Required Skills

- BS degree or equivalent work experience in a similar position may be substituted for educational requirement.
- 5+ years as a Fraud, Waste and Abuse Investigation work within a Healthcare insurance/payor organization
- QNXT & Fraud Shield strongly preferred, CPT and ICD10 coding a must.
- Excellent computer skills to include Microsoft Excel, HealthCare FraudShield software suite, QNXT claims adjudication system, savvy internet research skills and Ad hoc query and reporting.
- Highly organized, motivated self-starter with strong analytical and problem solving skills Excellent written and oral communication skills.
- Knowledge of medical terminology, CPT and ICD10 coding, analytical methodologies, and insurance and claim operations.

One of the following Certifications is preferred:
- Accredited Healthcare Fraud Investigator (AHFI)
- Certified Fraud Investigator

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Job Tags

Permanent employment, Work experience placement,

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