Fraud, Waste & Abuse Senior Analyst

POSITION PURPOSE:

Will support the detection, investigation, and prevention of healthcare fraud, waste, abuse, and payment integrity risks. The FWA Senior Analyst serves as the team's senior subject matter expert, responsible for overseeing complex investigations, guiding FWA Analysts, optimizing fraud detection strategies, and supporting claims integrity and payment accuracy initiatives. This role works closely with Claims, Operations, Medical Management, Provider Relations,Compliance, Legal, Risk, IT, and Underwriting to identify and mitigate fraud risks, improve payment accuracy, and strengthen the overall effectiveness of the FWA program.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES:

• Lead complex investigations involving members, providers, brokers, vendors, and potential fraud schemes.
• Review, validate, and provide guidance on investigations conducted by FWA Analysts.
• Determine case direction, evidence requirements, and appropriate disposition.
• Evaluate high-risk cases and recommend escalation to leadership, Legal, Compliance, or SIU functions when appropriate.
• Conduct advanced claims and billing reviews to identify fraud, abuse, and payment integrity concerns.
• Ensure investigations are completed accurately, timely, and in accordance with company standards.
• Monitor and evaluate the effectiveness of fraud detection rules, alerts, and monitoring programs.
• Recommend enhancements to improve fraud detection rates and reduce false positives.
• Identify emerging fraud schemes, provider trends, and operational risks.
• Support the development, calibration, and optimization of fraud detection models and business rules.
• Perform provider profiling, risk assessments, trend analyses, and claims data reviews.
• Maintain fraud reports, dashboards, and key performance indicators (KPIs).
• Provide day-to-day guidance, mentorship, and technical support to FWA Analysts.
• Assist with workload prioritization, case assignment, and performance monitoring.
• Review investigative documentation to ensure quality, consistency, and compliance.
• Support onboarding, training, and development of team members.
• Provide subject matter expertise and recommendations regarding investigative priorities and resource needs.
• Lead initiatives focused on payment integrity and prevention of inappropriate claim payments.
• Identify overpayments, recovery opportunities, and cost-containment strategies.
• Conduct targeted provider reviews and claim audits.
• Quantify financial impact, recoveries, savings, and cost avoidance resulting from FWA activities.
• Present investigative findings, trends, and recommendations to management
• Ensure compliance with internal policies, regulatory requirements, and industry standards.
• Support audits, compliance reviews, and regulatory inquiries.
• Assist in maintaining FWA policies, procedures, and investigative standards.
• Partner with Claims, Medical Management, Provider Relations, Legal, Compliance, Risk, IT, Underwriting, Operations and other stakeholders on FWA prevention initiatives.
• Support fraud awareness, education, and continuous improvement efforts across the organization.

REQUIRED QUALIFICATIONS:

• Degree in Healthcare Administration, Business Administration, Finance, Data Analytics, or a related field preferred. Equivalent experience may be considered.
• Minimum of 5 years of experience in health insurance operations, claims integrity, payment integrity, fraud investigations, medical claims auditing, SIU, or related functions.
• Minimum 2 years of experience leading projects, mentoring team members, or serving as a subject matter expert.
• International health insurance experience, adjudication of U.S. domestic, international, and PPGA claims and or/audit.
• Experience with provider investigations, claims auditing, and fraud detection programs.
• Language Skills: English and Spanish

Technical Skills:

• Advanced knowledge of healthcare claims processing, adjudication, and payment integrity principles.
• Strong understanding of Fraud, Waste & Abuse detection methodologies.
• Knowledge of U.S. domestic, international, and PPGA healthcare billing and reimbursement practices.
• Advanced understanding of ICD-10, CPT, HCPCS, and coding compliance principles.
• Ability to analyze large and complex datasets and identify trends and anomalies.
• Proficiency in Microsoft Excel, including pivot tables, formulas, and data analysis.

DESIRABLE QUALIFICATIONS:

• Experience in payment integrity functions, fraud detection, analytics tools.
• Intermediate level of Portuguese 

SOFT SKILLS AND COMPETENCIES:

• Strong coaching, mentoring, and team development skills.
• Excellent investigative judgment, problem-solving, and decision-making abilities.
• Ability to influence cross-functional stakeholders and drive results.
• Strong organizational, project management, and prioritization skills.
• Excellent written and verbal communication skills, including the ability to present findings to leadership.