Fraud Analysis Specialist

2 weeks ago

Hilliard, Florida, United States Independent Health Full time

Discover Your Career Path We value the unique contributions of each individual in our organization. Here, you can advance your career while enjoying exceptional benefits, perks, and a strong commitment to diversity and inclusion.

Position Overview The Fraud Analysis Specialist is responsible for developing, implementing, and managing the anti-fraud initiatives at Independent Health. This role includes conducting regular assessments of fraud risk and overseeing the program's effectiveness by collaborating with various departments responsible for fraud control. The specialist will investigate suspected fraudulent activities by analyzing standards of care, reviewing medical documentation, and evaluating other relevant information in line with Independent Health's Fraud Prevention Plan. Additionally, this role involves assessing data from computerized fraud detection systems to determine the validity of claims.

Qualifications A Bachelor's degree in criminal justice or a related discipline is required. Certification as a Fraud Examiner (CFE) is preferred.

Experience requirements include:

  • Five (5) years in insurance claims investigation or professional investigative work with law enforcement; or
  • Seven years of professional investigative experience in economic or insurance-related matters; or
  • Being a licensed medical professional qualified to assess medical claims.

Experience with medical insurance claims and conducting audits of medical records using standard coding systems (HCPC, CPT, ICD-9, ICD-10) is essential. Familiarity with managed care environments is preferred.

Key Skills

  • Ability to work independently with significant autonomy in directing investigations and coordinating program activities.
  • Strong organizational skills and proficiency in Microsoft Office, particularly Word and Excel; knowledge of claims audit software is advantageous.
  • Excellent verbal and written communication skills, with a proven ability to interact effectively with healthcare providers and gather necessary information.

Essential Responsibilities

  • Assist in identifying potential fraud and gathering necessary documentation for investigations.
  • Identify issues within medical records that may indicate fraudulent activity.
  • Research standards of care relevant to identified medical issues.
  • Review and analyze medical documentation to determine appropriate actions.
  • Collect, interpret, and summarize clinical data to guide case dispositions.
  • Support the identification, detection, and prevention of fraudulent activities.
  • Organize and manage reports and data effectively.
  • Identify opportunities for improving company policies and procedures based on analysis.
  • Develop a comprehensive anti-fraud program, including regular assessments of fraud risk and coordination of fraud control activities across the organization.

Compensation The hiring compensation range for this position is $60,500 - $77,500 annually, with variations based on skills, education, location, and experience. In addition to base compensation, associates may be eligible for performance incentives, a comprehensive benefits package, and generous paid time off.

Equal Opportunity Employer Independent Health is an Equal Opportunity / Affirmative Action Employer. We do not discriminate in employment practices based on race, color, creed, religion, sex, sexual orientation, gender identity, age, national origin, marital status, citizenship, disability, or any other characteristic protected by applicable law.

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