Fraud, Waste and Abuse Analyst

4 weeks ago

Miami, United States Alivi Full time

SUMMARY

DUTIES & RESPONSIBILITIES

FWA Monitoring and Analysis:

- Conduct regular reviews and audits of transactions, claims, and provider/member activities to identify potential instances of fraud, waste, or abuse.
- Analyze data trends and patterns to detect irregularities or suspicious activities.
- Utilize analytical tools and methodologies to assess compliance with regulatory requirements and organizational policies.

Investigation and Reporting:

- Performs data mining and analyses to detect aberrancies/outliers in claims and data to proactively seek out and report FWA.
- Conduct thorough investigations into suspected cases of fraud, waste, or abuse, including gathering evidence, interviewing stakeholders, and documenting findings.
- Prepare detailed reports documenting investigation outcomes, including recommendations for corrective action and risk mitigation strategies.
- Collaborate with relevant departments, such as legal, compliance, and risk management, to address compliance concerns and implement remedial actions.
- Prepares any Health Plan Compliance reports related to FWA

Training and Education:

- Develop and deliver training programs and educational materials to enhance awareness of compliance requirements and FWA prevention strategies among staff and providers.
- Stay updated on emerging trends, technologies, and regulatory changes in the healthcare industry.
- Promotes and contributes to a positive, problem-solving environment.
- Performs other related duties as assigned by management.

**REQUIREMENTS**:

- Associate degree or equivalent preferred.
- Required to have 3+ years of experience working for a Managed Care Organization, specifically with the transportation benefit, or for a transportation broker operating in multiple states.
- Excellent written and oral communication skills.
- Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm.
- Acute attention to detail.
- Ability to deal effectively with a variety of individuals at all organizational levels.
- Ability to communicate professionally and effectively in person, on the phone, electronically, or through other means to individuals and groups.
- Good judgment with the ability to make timely and sound decisions.
- Professional appearance and demeanor.
- Ability to effectively present information and respond to questions.

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