Cleveland - BWC Fraud Analyst PN: 20066685

Ohio Department of Administrative Services • Cleveland, OH

10h • Onsite

About The Position

Serve as a technical resource for identifying fraudulent activity by developing criteria, detection models, and analytical approaches that surface high‑risk behaviors across claims, providers, employers, and injured workers.
Conduct complex data mining, outlier analysis, and trend identification across large, stratified datasets to uncover anomalies and patterns indicative of fraud or abuse.
Use advanced technologies (e.g., FMS, CORESuite, IBM Cognos, Tableau) to design databases, compile large datasets, and create dashboards and reports that support fraud investigations.
Analyze cross‑match data from state and out‑of‑state agencies (e.g., wage, payroll, medical billing) to identify potential dual‑benefit recipients or other fraudulent activity.
Partner with investigative units to review allegations, validate claims activity, gather information from employers and providers, and support both criminal and civil case development.
Develop tailored reports, trend analyses, and retrospective reviews to support investigative units and operational decision‑making across the Special Investigations Department.

Requirements

• 54 mos. exp. in private insurance organization as claims representative, criminal investigator, rehabilitation case manager or equivalent position; 6 mos. exp. in operation of personal computer; valid driver’s license. The final applicant accepted for this position must successfully pass state highway patrol personal background check prior to employment.
• completion of undergraduate core coursework in business, criminal justice, humanities, social & behavioral science, education or related field; 18 mos. exp. in insurance organization as claims representative, criminal investigator, rehabilitation case manager or equivalent position; 6 mos. exp. in operation of personal computer; valid driver’s license. The final applicant accepted for this position must successfully pass state highway patrol personal background check prior to employment .
• 18 mos. exp. as Workers' Compensation Claims Specialist, 16722, or managing caseload of workers' compensation lost-time disability claims which involved making decision to allow or deny claim, verifying appropriateness of medical treatment & charges, pre-authorized medical treatment, equipment, supplies & special travel arrangements, researching, negotiating, authorizing & issuing settlement of claims &/or conducting field inquiries to accurately assess claim information & resolving disputed condensability & benefit level for Ohio Bureau Of Workers' Compensation; 6 mos. exp. in operation of personal computer; valid driver’s license. The final applicant accepted for this position must successfully pass state highway patrol personal background check prior to employment.
• 18 mos. exp. as BWC Fraud Investigator, 26261.
• Knowledge of Business, Criminal Justice, Humanities, Social & Behavioral Science Education or related field; BWC Policies & Procedures, Laws & Regulations related to Adjudication & Maintenance of Workers’ Compensation Claims; Agency, State & Federal Statutes, rules, regulations & procedures applicable to investigation, evidence gathering & search & seizure; English; oral & written communication; public relations; interviewing techniques; principles of customer service; fundamental math operations; standard business practices.
• Skill in use of personal computer; word processor; database & spreadsheet software; statistical analysis, data visualization & analytical software used in Fraud Detection.
• Ability to communicate effectively & professionally with injured workers, employers, legislators, health care providers & public; make complex decisions regarding claims activity; read & understand medical reference manuals; write clear, concise & professional correspondence & reports; collate & classify information about data, people or things; assess immediate situation & make split-second decisions; respond to sensitive inquiries from & contacts with injured workers, employers, legislators, health care providers & members of general public.

Responsibilities

• Serve as a technical resource for identifying fraudulent activity by developing criteria, detection models, and analytical approaches that surface high‑risk behaviors across claims, providers, employers, and injured workers.
• Conduct complex data mining, outlier analysis, and trend identification across large, stratified datasets to uncover anomalies and patterns indicative of fraud or abuse.
• Use advanced technologies (e.g., FMS, CORESuite, IBM Cognos, Tableau) to design databases, compile large datasets, and create dashboards and reports that support fraud investigations.
• Analyze cross‑match data from state and out‑of‑state agencies (e.g., wage, payroll, medical billing) to identify potential dual‑benefit recipients or other fraudulent activity.
• Partner with investigative units to review allegations, validate claims activity, gather information from employers and providers, and support both criminal and civil case development.
• Develop tailored reports, trend analyses, and retrospective reviews to support investigative units and operational decision‑making across the Special Investigations Department.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed