Fraud Waste & Abuse (FWA) Investigator

Summa Health•Akron, OH

64d•$28 - $42•Hybrid

About The Position

Are you fueled by curiosity, driven by justice, and relentless in your pursuit of the facts? Step into a high-impact role where your investigative skills help safeguard healthcare systems from fraud, waste, and abuse - and ensure that resources go where they're truly needed. We're looking for a Fraud, Waste, and Abuse (FWA) Investigator to lead complex investigations, analyze patterns, ensure compliance, communicate via phone or in writing with members and providers and collaborate across teams to uphold compliance and accountability. Summary: Conducts medium to high complexity investigations under general supervision to effectively pursue the identification, prevention, and investigation of healthcare fraud, waste and abuse (FWA), to facilitate the recovery of lost funds, and to comply with state and federal regulations mandating fraud plans and practices. Maintains knowledge of current schemes and determines impact to the plan. Ensures the SIU processes and procedures reflect current industry norms.

Requirements

Bachelor's Degree, or equivalent combination of education and experience.
Five (5) years Fraud, Waste and Abuse identification and investigation.
Special Investigations Unit (SIU) experience in a managed care setting.
Demonstrate intermediate proficiency in MS Office, Project, and database management.
Maintain excellent working knowledge of process improvement techniques, methodologies and principles applying these in the normal course of operations.
Demonstrate excellent analytical and problem-solving skills.
Apply principles of logical thinking to define problems, collect data, establish facts, and draw valid conclusions.
Organize and manage time to accurately complete tasks within designated time frames in fast paced environment.
Skilled at conducting analysis of claims data to identify aberrant patterns and support investigative activities.
Maintain current knowledge of and comply with regulatory and company policy and procedures.
Sit for prolonged periods of time.
Bend, stoop, and stretch.
Lift up to 20 pounds.
Manual dexterity to operate computer, phone, and standard office machines

Nice To Haves

Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) preferred.
Lean Six Sigma Yellow Belt preferred

Responsibilities

Works within industry groups, and known fraud, waste and abuse (FWA) data repositories to ensure a current knowledge and understanding of FWA schemes and industry practices.
Performs data mining to determine if identified FWA schemes are impacting the plan, summarize those findings and make recommendations for action including reporting and prevention. Documents all findings, decisions, and actions.
Maintains working knowledge of relative enterprise and local information systems, databases, data schemas, software packages, and business operations to facilitate precise, reliable and accurate fulfillment of information needs related to corporate operations.
Maintains employee, provider and member education as it relates to FWA.
Investigates assigned cases of FWA including coordinating and conducting on-site and desk-top audits, member and stakeholder interviews, outlier billing identification, contract and regulatory guidance analysis.
Manages the SIU prepay review process which includes requesting the implementation of prepay reviews, organizing the records, and reviewing submitted records or sending to the appropriate area for a medical/coding review.
Complies with SIU Policies and procedures as well as goals set by SIU leadership.
Prepares SIU documentation for arbitrations, legal procedures, and settlements.
Recommends claim handling based on medical record review and compliance with industry standard claim coding (CPT, HCPCs, ICD10. etc,) and payment policies.
Ability to effectively interact with populations of patients/customers with an understanding of their needs for self-respect and dignity.