LOCATION: Remote – must live in North Carolina or within 40 miles of the NC border.
GENERAL STATEMENT OF JOB
The Healthcare Fraud Analyst works under the direct supervision of the Special Investigations Director in the Special Investigations Unit (SIU). The Healthcare Fraud Analyst is responsible for identification and detection of potential Healthcare fraud, waste and abuse within the Vaya Health Network. This includes gathering, analyzing and interpreting complex data and information to provide meaningful results in developing leads, collaboration with internal resources as well as compliance with state and federal requirements for fraud, waste and abuse detection and prevention. The Healthcare Fraud Analyst will use tools such as MIS reports and dashboards, the IBM Fraud Abuse Management System (FAMS), and Excel spreadsheets to review provider claims data for aberrant billing patterns and practices. The Healthcare Fraud Analyst will generate investigation referrals based on information gathered during data mining and service line research activities.
ESSENTIAL JOB FUNCTIONS
Data Mining and Analysis:
- Conduct data mining and analysis activities to identify potential fraud, waste or abuse in claims data
- Analyze and interpret data analytics packages generated by IBM FAMS
- Act as liaison between the Vaya Special Investigations Unit and IBM FAMS analysts
- Identify provider billing trends and make recommendations to SIU leadership regarding areas of potential risk to the organization
- Communicate meaningful insights by creating pivot tables, charts and slide presentations and present findings to colleagues and leadership
- Work collaboratively with SIU investigators and leadership to relay areas of potential fraud or billing abuse
Investigation consultation:
- Assist investigators in developing member and recipient investigation sampling methodologies
- Assist investigators in organizing claims data included in referrals sent to the Division of Health Benefits Office of Compliance and Program Integrity for suspected fraud
Collaboration with other Vaya Departments:
- May represent the SIU on cross functional project teams that require data analysis and interpretation
Other duties as assigned.
KNOWLEDGE, SKILL & ABILITIES REQUIRED:
- Experience in auditing, data analysis, or fraud detection
- Strong analytical and problem-solving abilities
- Demonstrated ability to work individually and as a team member
- Possess a willingness to learn and keep abreast of technological changes affecting the primary position functions
- Excellent written and verbal communication skills
- Ability to analyze and interpret claims data and present findings and recommendations to stakeholders
- Advanced proficiency in Microsoft Office Suite, Power BI, etc.
- Technical writing skills
- Ability to set and meet deadlines
- Ability to work in high-pressure situations
- Experience with statistical software such as SPSS (IBM), SAS (Statistical Analysis Software), R (R Foundation for Statistical Computing), or Microsoft Excel
- Reporting and data visualization skills
- Excellent attention to detail
QUALIFICATIONS & EDUCATION REQUIREMENTS
Associate degree in Information technology, Data Analytics, Statistics, Business, Human Service field, Health Law, Criminology, or related field required. Bachelor’s degree preferred. Must have at least 2 years of experience with healthcare data analytics/informatics including duties related to prevention, detection, or investigation of healthcare fraud, waste, or abuse.
PHYSICAL REQUIREMENTS:
- Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
- Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists, and fingers.
- Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
- Mental concentration is required in all aspects of work.
RESIDENCY REQUIREMENT: Must live in North Carolina or within 40 miles of the NC border.
SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.
DEADLINE FOR APPLICATION: Open Until Filled
APPLY: Vaya Health accepts online applications in our Career Center, please visit
Vaya Health is an equal opportunity employer.
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