[Hiring] Sr. FWA Analyst @Team8

Role Description

We are looking for a Sr. FWA Analyst experienced in discovering medical billing errors and fraudulent billing patterns of medical claims for commercial payers.

• Proactively identify potential instances of fraud, waste, and abuse through data analysis using company systems and tools
• Support engineering and data science teams with audit and FWA concepts, data mapping, and defining data requirements
• Determine the likelihood of cases being true error/fraud, based on real-life experience
• Validate and help to tune anomaly detection algorithms

Qualifications

• Hands-on experience exploring and investigating potential medical billing errors/fraud using analytic and SQL/graph-based tools
• Extensive knowledge of medical terminology, medical records, health information management, medical coding, DRG methodologies, CPT/HCPCS coding guidelines, physician specialty guidelines, reimbursement programs, claims adjudication processes, member contract benefits, regulatory agency policies (CMS/HCFA, DOI, state regulations), and provider billing systems and practices
• Strong analytical skills and ability to approach tasks in a scientific manner
• Background in SIU or Payment Integrity
• Independent, Organized, and with excellent communication skills

Requirements

• Medical/clinical background
• Experience with Pharma claims
• Billing/coding experience