SIU Fraud Analytics Specialist

The SIU Fraud Analytics specialist is part of a team focused on the prevention, detection, investigation, and reporting of healthcare fraud, waste, and abuse, program integrity initiatives, and the recovery of overpayments in a multi-payer environment. This is a data-intensive position. The Specialist is or will become a data mining and analysis expert, responsible for leveraging analytical tools to provide in-depth data analysis in support of fraud investigations, identifying outliers and/or aberrant billing patterns; potential fraud, waste, and abuse (FWA); and vulnerabilities or overpayments; as well as proactively generating leads for further investigation in pursuit of program integrity. The Specialist may occasionally assist other team members in fulfilling data requests and analytics for MFCU, the WVOIC, the ODI, the USAO and other law enforcement or regulatory entities. The Fraud Analytics Specialist will also conduct reviews of payment integrity matters (where fraud is not suspected), completing a thorough and ethical investigation.

Required:

• EDUCATION: Associate's degree in any field, with preference for degree in Criminal Justice, Data Analytics, Health Informatics, Health Information Management, or related field. (Two [2] years of relevant experience as described below in QUALIFICATIONS DESIRED section may be substituted for the required education.)
• EXPERIENCE: At least 1 year of experience working with Microsoft Excel in a professional environment.
• Advanced proficiency in Microsoft Excel; basic proficiency in Word, Outlook and other common programs.
• Strong organizational and analytical skills.
• Detail oriented, with a high level of accuracy.
• Effective written and oral communication skills.
• Ability to plan and execute projects independently and meet tight deadlines.

Desired:

• Education: Bachelor's degree in Accounting, Business, Criminal Justice, Data Analytics, Health Informatics, Health Information Management, or related field; or a Bachelor's degree in any field and a Master's Degree in any fraud-related discipline.
• At least 2 years of relevant experience such as: SIU, healthcare fraud investigation, medical claim investigation, healthcare program integrity, data mining or analytics, healthcare claims payment processing, clinical experience, compliance, or certification as AHFI, CPC/CCP/CCS/CMC, or CFE.
• Proficiency in fraud analytics.
• Advanced technical skills related to data mining and analysis of healthcare claims data.
• Experience with SQL/Microsoft Report Builder and Report Manager.
• Experience in Medical Terminology and/or Coding.
• Experience in a federally regulated environment such as Medicaid or Medicare Advantage.

Responsibilities:

• Leveraging analytic tools to provide in-depth data analysis in support of fraud investigations and payment integrity activities.
• Conducting strategic analysis of healthcare claims data from initial data scoping through transformation and validation, and conveying results in verbal, written, and visual formats.
• Analyzing healthcare claims data and other relevant information reactively, in response to allegations of FWA, and proactively, to identify trends and patterns indicative of FWA.
• Utilizing fraud detection software and large data sets to identify outliers and inform decision-making related to FWA investigations and the identification and recovery of overpayments.
• Obtaining, cleaning, normalizing, and validating healthcare claims data for the purposes of supporting FWA investigations and informing investigative and recovery decisions.
• Drafting clear and concise, yet appropriately detailed reports of findings which may include recommendations related to case disposition, corrective actions, and/or process improvements.
• Analyzing and synthesizing information from multiple sources including claims data, contracts, enrollment data, provider manuals, educational materials, bulletins, and state and federal regulations, to determine impact on claims payment as it relates to SIU cases or leads.
• Responding to requests for information from various sources, including Medicaid, I-MEDIC, MFCU, and the WV OIC.
• Expertise in the use of fraud detection software and case tracking system.
• Creating and delivering training on databases, analytics software, and other relevant systems and techniques.
• Identifying and recommending process improvements to reduce FWA.
• Tracking, trending, and reporting identified metrics, including dashboard reporting.
• Maintaining technical knowledge and skills by attending professional conferences and trainings, obtaining or retaining professional certification(s), and pursuing constant learning through membership in relevant professional organizations.
• Investigating matters of payment integrity as assigned by the FWA Data Analytics Manager.