Fraud, Waste, and Abuse (FWA) Analyst II

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The Fraud, Waste, and Abuse (FWA) Analyst II identifies and develops potential healthcare fraud leads through data mining, claims analysis, and investigative research.

Lead Development & Fraud Detection

• Develop proactive and reactive leads to identify potential fraud, waste, and abuse.
• Generate FWA leads by mining claims databases, reporting tools, and investigative systems.
• Validate and refine leads generated by business rules to assess their credibility and investigative value.
• Examine spike analyses, utilisation trends, payment anomalies, and outlier reports for unusual billing patterns.
• Evaluate provider, member, pharmacy, DME, transportation, and facility billing for indicators of fraud or abuse.
• Monitor internal and external intelligence sources to detect emerging fraud schemes and patterns.

Data Analysis & Research

• Perform detailed quantitative and qualitative analysis of medical and pharmacy claims data.
• Analyse CPT, HCPCS, ICD, DRG, NDC, modifier usage, and reimbursement trends.
• Review provider billing history, peer comparisons, utilisation metrics, and financial impact analyses.
• Conduct research utilising internal systems, external public records, licensing boards, sanctions lists, and other investigative resources.
• Analyse relationships among providers, members, facilities, and associated entities to identify potential schemes or collusive activity.

Case Evaluation & Recommendations

• Develop comprehensive lead summaries outlining allegations, supporting evidence, and identified risk indicators.
• Present analytical findings and recommendations to SIU leadership and investigative staff.
• Determine whether findings support escalation to a formal investigation, monitoring activity, or closure.
• Document investigative rationale and supporting evidence in accordance with SIU policies and regulatory requirements.
• Provide actionable recommendations based on analytical findings and business intelligence.

Collaboration & Operational Support

• Partner with investigators, clinicians, legal, compliance, and business partners regarding potential FWA concerns.
• Participate in fraud trend discussions and special projects aimed at strengthening fraud detection efforts.
• Support continuous improvement initiatives involving business rules, data mining strategies, and lead generation methodologies.
• Assist with training and knowledge related to emerging fraud schemes and healthcare billing practices.

Compliance & Quality

• Ensure all activities comply with CMS, state Medicaid regulations, Medicare requirements, organisational policies, and SIU procedures.
• Maintain confidentiality and safeguard sensitive information.
• Meet departmental productivity, quality, and timeliness standards.
• Support internal audits, quality reviews, and regulatory reporting activities.

Required Qualifications

• 3+ years of healthcare data analysis, SIU, claims analysis, auditing, payment integrity, or healthcare fraud experience.
• Strong analytical and critical-thinking skills with the ability to identify trends and anomalies.
• Experience interpreting large healthcare datasets and transforming findings into actionable insights.
• Working knowledge of healthcare claims processing and coding methodologies.
• Ability to travel up to 10%

Preferred Qualifications

• Experience in a healthcare payer Special Investigations Unit (SIU).
• Knowledge of Medicare, Medicaid, Commercial, and Marketplace healthcare programs.
• Understanding of medical and pharmacy claim data.
• Working knowledge of CPT, HCPCS, ICD-10, DRG, and NDC coding structures.
• Familiarity with healthcare payment methodologies and reimbursement models.
• Experience using fraud detection tools, business rule engines, and investigative case management systems.
• Experience with Tableau, Power BI, or equivalent analytical platforms.
• Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), or similar certification.
• Excellent verbal, written, and presentation skills.
• Strong organisational and time-management abilities with the capability to manage multiple priorities.
• Bilingual in English/Spanish.

Education

• Bachelor's degree or equivalent combination of education and experience.

Anticipated Weekly Hours 40

Time Type Full time

Pay Range $43,888.00 - $85,068.00