Certified Fraud Examiner Medicare/Medicaid Program Integrity Analyst

Seeking a full-time, remote, Program Integrity Analyst to assist with investigations and administrative actions relating to Medicare/Medicaid claims.Essential Duties and Responsibilities· Perform evaluation and development of leads, complaints, and/or investigations to determine if further investigation and administrative actions are warranted· Conduct independent reviews resulting from the discovery of situations that potentially involve fraud or abuse· Utilize basic data analysis techniques to detect aberrancies in Medicare and Medicaid claims data, and proactively seeks out and develops leads/investigations received from a variety of sources (e.g., CMS, OIG, 1-800-MEDICARE, and fraud alerts)· Review information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare and Medicaid policies and initiate appropriate action· Make potential fraud determinations by utilizing a variety of sources such as internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid regulations, and the Social Security Act· Compile and maintain documentation and information related to investigations, cases, and/or leads· Participate in onsite audits in conjunction with investigation development· Develop and prepare potential Fraud Alerts and program vulnerabilities for submission to CMS. Share information on current fraud investigations with other Medicare contractors and state Medicaid agencies, law enforcement, and other applicable stakeholders· Prepare and submit external correspondence and reports, including, but not limited to, overpayment letters, fraud case referrals, suspensions, rebuttals, Medicare/Medicaid findings, reports, and administrative action recommendations· Submit suspension notifications to providers upon suspension approval· Prepare and submit ADR letters to providers associated with requests for medical record requests or suspension overpayment determinations· Serve as mentor/trainer to new Program Integrity staff· Perform other duties as assigned by PI Supervisor or PI Manager that contribute to task order goals and objectives Competencies· Excellent research and organization, prioritization, and time management skills· Excellent verbal and written communication skills· Ability to work independently with minimal supervision· Ability to multi-task in a fast-paced environment· Knowledge of statistics, data analysis techniques, and PC skills are preferred Education and Experience· High School Diploma or G.E.D equivalent; preference for completed college degree, technical degree related to the position (i.e. criminal justice, statistics, data analytics, etc.· At least 1 year of experience in Program Integrity investigations/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information and making appropriate decisions· Preference given to individuals that have attained a Certified Fraud Examiner (CFE) designation Company DescriptionWCC is a small, women-owned business specializing in benefit payment validations. In addition to assisting Federal Agencies with their workers compensation programs, WCC supports Centers for Medicare and Medicaid Services (CMS) Prime contractors with their waste, fraud and abuse initiatives, providing data analytics and investigative solutions. WCC is an Equal Opportunity Employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, caste, disability, veteran status, and other legally protected characteristics and maintain a drug-free workplace.