Financial Analyst - Fraud, Waste and Abuse (FWA)

Doctors Healthcare Plans • Coral Gables, FL

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About The Position

The Financial Analyst - Fraud, Waste and Abuse (FWA) is responsible for identifying, investigating and preventing fraudulent, wasteful and abusive activities related to healthcare claims, insurance, government programs, or organizational operations. This role uses data analysis, investigative techniques, and regulatory knowledge to detect suspicious patterns, minimize financial losses and ensure compliance with applicable laws and company policies.

Requirements

• Bachelor’s degree
• Three-year experience in healthcare and/or Medicare Advantage plans
• Experience with healthcare claims analysis, large data sets and claim analytics
• Ability to manage multiple investigations simultaneously
• Able to meet deadlines, multi-task and thrive in high-pressure environment
• Excellent oral and written communication
• Proficiency with MS office with advanced skills in Excel and SQL
• Experience with PowerBI and developing dashboards
• Ability to work independently and collaboratively in a team environment

Responsibilities

• Analyze medical, pharmacy, provider, and member-level claims data to identify potential FWA, overutilization, unusual billing patterns
• Perform data mining, auditing, trend analysis, outlier detection, and root-cause analysis across providers, members, CPT codes, diagnosis codes, DRG codes, and claim types.
• Generate and prioritize investigative leads
• Support pre-payment and post-payment review activities
• Recommend enhancements to claim edit rules and controls to prevent future improper payments
• Document models, provide investigative summaries and recommendations for review by FWA, Finance, Compliance, Medical Management, and other leadership.
• Produce FWA dashboard, and reports on savings and recoveries, trends and emerging risks, provider and member monitoring, etc.
• Support FWA program reporting, audit responses, policy/procedure development, and operational documentation
• Maintain confidentiality of sensitive information and investigative findings
• Meet performance goals as established for the position
• Perform additional duties and responsibilities as assigned by management

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level