Fraud, Waste & Abuse Analyst

POSITION PURPOSE:

Will support the detection, investigation, and prevention of healthcare fraud, waste, abuse, and payment integrity risks. The FWA Analyst will review medical claims, identify suspicious billing patterns, conduct investigations, analyze data, and support claims integrity and cost-containment initiatives. This role contributes to fraud prevention efforts through effective case management, alert monitoring, trend analysis, and collaboration with cross-functional business partners while ensuring compliance with company policies and regulatory requirements.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES:

• Review medical claims and related documentation to identify potential fraud, waste, abuse, and payment integrity concerns.
• Conduct preliminary investigations involving members, providers, brokers, vendors, and claims-related activities.
• Analyze medical records, billing information, coverage provisions, and claims data for irregularities and suspicious activity.
• Identify duplicate billing, coding discrepancies, unbundling, upcoding, excessive utilization, and other abuse indicators.
• Gather and document evidence, prepare investigative summaries, and maintain complete case records.
• Escalate complex or high-risk cases to the Lead FWA Analyst or FWA Manager as appropriate.
• Utilize data analytics, reporting tools, and fraud detection systems to identify trends, anomalies, provider outliers, and emerging fraud risks.
• Monitor fraud detection alerts and recommend opportunities for rule enhancements and reduction of false positives.
• Assist with fraud monitoring reports, dashboards, and performance metrics.
• Support provider reviews, claims audits, and targeted investigations based on identified risk indicators.
• Support claims integrity initiatives focused on payment accuracy and cost containment.
• Identify potential overpayments, recoveries, savings opportunities, and financial impact associated with investigative findings.
• Ensure investigations comply with company policies, regulatory requirements, confidentiality standards, and ethical guidelines.
• Support audits, compliance reviews, and related inquiries as required.
• Partner with Claims, Medical Management, Provider Relations, Compliance, Legal, IT, Underwriting, Operations, and other stakeholders.
• Participate in fraud awareness initiatives, training programs, and process improvement efforts.
• Stay current on healthcare fraud schemes, payment integrity trends, and industry best practices.
• Recommend process improvements that enhance fraud prevention and investigative effectiveness.

REQUIRED QUALIFICATIONS:

• Degree in Healthcare Administration, Business Administration, Finance, Data Analytics, or a related field preferred. Equivalent experience may be considered.
• Minimum 2 years of experience in health insurance operations, claims processing, claims adjudication, medical claims review, auditing, payment integrity, fraud investigations, or data analysis.
• Experience with US domestic, international and PPGA healthcare insurance claims
• Language Skills: English and Spanish

Technical Skills:

• Knowledge of US domestic, international, and PPGA healthcare insurance operations, claims adjudication, billing, and reimbursement methodologies.
• Understanding of healthcare fraud schemes, payment integrity risks, and investigative practices.
• Knowledge of benefit interpretation and coverage analysis.
• Strong analytical, investigative, critical thinking, and problem-solving abilities.
• Ability to identify trends, anomalies, and patterns within large datasets.
• Proficiency in Microsoft Excel, including pivot tables, formulas, and data analysis.

DESIRABLE QUALIFICATIONS:

• Experience in payment integrity functions, fraud detection, analytics tools.
• Working knowledge of ICD-10, CPT, HCPCS, and medical coding principles preferred.
• Experience with Power BI, Tableau, SQL, or similar analytical tools is a plus.
• Intermediate level of Portuguese 

SOFT SKILLS AND COMPETENCIES:

• Ability to work effectively across multiple systems and technologies.
• Strong organizational, communication, and time-management skills.
• Ability to manage multiple priorities in a fast-paced environment.
• Ability to work independently while maintaining confidentiality and professionalism.
• Strong collaboration and stakeholder engagement skills.