Current jobs related to Fraud Waste - King of Prussia - Worldwide Insurance Services
-
FWA Negotiation Specialist
1 week ago
King of Prussia, United States Worldwide Insurance Services Full timeJob DescriptionJob DescriptionWe are hiring for Fraud, Waste, & Abuse Negotiation Specialists to join the team! A Fraud, Waste, & Abuse (FWA) Negotiation Specialist is responsible for the day-to-day execution of our enhanced claim control strategies. The specialist is on the front line of GeoBlue's effort to reduce unnecessary medical spending and make...
-
Manager - Global Networks
2 months ago
King of Prussia, United States Worldwide Insurance Services Full timeJob DescriptionJob DescriptionWe are seeking a Manager to join our Global Networks team! The primary responsibility of this position is to oversee the Global Networks staff and activities. This position is responsible for applying knowledge of our international network and process in leading the Provider Relations and Provider Finance teams with support from...
Fraud Waste
2 months ago
Responsibilities:
- Evaluate claims and determine the most appropriate remedy for preventing fraud, waste, or abuse if applicable.
- Contact external 3rd parties through outbound call or email to verify claim information.
- Negotiate high-cost claims with non-contracted providers.
- Validate accuracy of claim charges and initial processing decisions.
- Coordinate activities across other departments (ex. Clinical, Provider Finance, Customer Service, Claims) and external entities (ex., home plans).
- Determine if claim costs are Usual, Customary, and Reasonable through comparative analysis with historic claims.
- Perform online research to fill in gaps in existing tools and understanding.
- Attempt to obtain written confirmation of falsified claims through independent investigation and recorded interviews/interrogations.
- Perform analysis on historic claims to determine full scope of identified fraudulent activity.
- Track activity and produce reports to measure impact and document actions.
- Other duties as assigned.
Requirements:
- Bachelor’s degree or equivalent experience required; advanced degree or certification valued.
- Minimum of 3 years insurance industry experience required; 5-10 preferred.
- Strong attention to detail and problem-solving skills.
- Strong working knowledge of international health insurance claims.
- Knowledge of US Domestic health insurance claims is a plus.
- Previous experience navigating Geo-blue's various claim systems is a significant plus.
- Prior experience identifying or investigating fraud, waste, and abuse is not required, but is highly valued.
- Excellent written and verbal communication skills.
- Strong organizational skills, with the ability to manage multiple competing tasks at the same time.
- Ability to deal with ambiguity and drive for resolution.
- Willingness and ability to learn and apply new skills.
- Multi-lingual strongly preferred.
- Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).
Working Conditions:
- Flexibility to work in an office and/or at-home, remote office environment.
- Schedule flexibility is occasionally necessary in this position. Individual may be required to attend key business/departmental meetings and/or perform certain business critical job functions outside of normal working hours.
- Physical Demands: Must be able to communicate internally and externally through receiving and responding to auditory and visual methods.
Competitive base pay starting at $60,743 annually.
Compensation is based on prior/relevant experience and skill level in a similar role.
This job description reflects management’s assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned.