Fraud Waste and Abuse - Sr. Analyst
About The Position
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The Sr. Analyst, Fraud, Waste, and Abuse (FWA) will assist in detecting, investigating, remediating and referring to state regulatory agencies incidents of FWA arising in connection with medical, behavioral, transportation, and other healthcare services. The Sr. Analyst will assist in determining correct coding, review claims, and billing data from all types of healthcare providers for aberrant billing patterns. Activities include reviewing billing activity for state agency referrals, assisting in the investigation and triage of FWA complaints, coordination with other departments and assist in prevention activities including training of internal staff and internal departments.
Requirements
- 3-5 years’ work experience
- CPC or equivalent coding certification
- Working knowledge of standard industry coding guidelines such as CPT, HCPCs, ICD-10
- Experience reviewing medical records to ensure that documentation matches services billed
- Experience reviewing detailed data to interpret claims data
Nice To Haves
- Medicaid experience
- Strong analytical skills
- Working knowledge of problem solving and decision-making skills
- Adept at collaboration and teamwork
- Attention to detail
- Associate’s degree or equivalent post-high school education preferred
Responsibilities
- Leverage analytical skills to review claims data and identify patterns of suspected potential FWA.
- At the direction of the Sr. Manager, FWA, assist in the triage, preliminary investigation of all internal and external FWA complaints
- Refer all cases of suspected FWA to regulatory agencies within required timeframes, ensuring all documentation meets federal, state, and internal compliance standards.
- Assist in the monitoring of the FWA hotline and FWA shared email box
- Participate in the prepayment review process including detailed review of medical records against claims data to look for inappropriately billed services and determine if there is any suspected FWA
- Data mining and trending of claims data to review for potential areas of risk and/or escalation of inappropriate billing which may rise to the level of suspected FWA
- Assist Sr. Manager, FWA and FWA Director, and collaborate with cross-functional partners (e.g., Compliance, Legal, Provider Relations) on ad hoc deliverables, investigations, and reporting.
- Assist in the maintenance of the QuickBase database of all FWA cases
- Independently initiate leads and conduct case reviews, producing detailed investigative reports and clearly communicating findings and recommendations
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
