Fraud Examiner
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Job Description
Fraud Examiner analyzing healthcare claims and financial data for Healthfirst’s Special Investigations Unit. Supporting referrals, audits, restricted-recipient processes, and Fraud, Waste and Abuse investigations.
Responsibilities:
- Provide support to SIU investigators through preliminary investigative tasks and data analysis
- Synthesize, analyze, and process healthcare claims data and financial information in Excel
- Create tables and pivot tables for internal review and reporting
- Maintain an Agency Referral Log of incoming agency requests for information
- Obtain information in response to RFIs for legal department approval
- Monitor the Restricted Recipient Program by notifying departments of incoming informational packets
- Mail Restricted Recipient Program information to members
- Coordinate member and provider packets for members restricted by the Member Review and Restriction Committee
- Monitor internal mailboxes for investigative inquiries
- Assist investigators with interviews, information review, and determining further investigative steps
- Attend Marketing Incidents Committee meetings, manage notes and minutes, and update the Marketing Log with decisions and directives
- Assist SIU colleagues with Fraud, Waste and Abuse issues and problem solving
- Perform additional duties, including minor administrative tasks supporting the department
Requirements:
- AA/AS degree from an accredited institution
- Intermediate Word and Outlook skills
- Intermediate/Advanced Excel skills including pivot tables and basic formulas
- Data analysis experience
- Prior experience in either insurance claims investigation/audit or other professional investigations
- Critical thinking, analytical skills and teamwork experience
- Good oral and written communication skills, including an ability to summarize data analysis and contribute to investigative reports
- Preferred: Bachelor’s Degree from an accredited institution
- Preferred: Experience with Tableau and/or SAS
- Preferred: Knowledge of Medicare and Medicaid and/or healthcare claims data
- Preferred: Knowledge of medical claims processing and investigations and ability to read medical records
- Preferred: Knowledge of applicable fraud statutes, regulations, CMS guidelines, and Federal and State insurance reporting requirements
- Preferred: Spanish or other language proficiency
Benefits:
- Medical, dental and vision coverage
- Incentive and recognition programs
- Life insurance
- 401k contributions
- Competitive compensation and benefits package
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