FWA Triage and Liaision - Hybrid

Blue Cross Blue Shield of Arizona•Phoenix, AZ

29d•Hybrid

About The Position

The Fraud, Waste, and Abuse (FWA) Triage and Liaison serves as a vital point of contact and coordinator within the organization, responsible for receiving, assessing, and facilitating the investigation of suspected instances of fraud, waste, and abuse. This position ensures prompt and accurate evaluation of reports, collaborating with internal and external stakeholders (including vendors and segment General Managers).

Requirements

2 years of experience in compliance, investigations, auditing, or a related field
Familiarity with laws and regulations related to fraud, waste, and abuse, such as the False Claims Act, Anti-Kickback Statute, and relevant federal/state regulations.
Experience with healthcare fraud shield systems and demonstrated ability to tailor such systems to meet business requirements.
Bachelor’s degree in Criminal Justice, Business Administration, Public Health, Compliance, or related field
Proficiency in case management systems, Microsoft Office Suite, and data analysis tools.
Strong multitasking, analytical, organizational, and interpersonal communication skills.
Ability to handle confidential and sensitive information with integrity
Demonstrated ability to work independently and collaboratively across departments in a fast-paced environment.

Nice To Haves

4 years of experience in compliance, investigations, auditing, or a related field
Advanced degree preferred
Experience in healthcare, insurance, or government programs dealing with FWA issues.
Certification in compliance, fraud examination, or auditing (e.g., CFE, CHC, CIA) is an asset.
Strong problem-solving and conflict resolution skills.
Excellent written and verbal communication skills, including the ability to prepare clear and concise reports.
Commitment to upholding ethical standards and promoting a culture of accountability.

Responsibilities

Receive, review, and categorize incoming reports of suspected fraud, waste, and abuse from internal and external sources.
Conduct initial triage to determine the severity, credibility, and urgency of reported cases.
Document findings, maintain systematic case records, and ensure information is handled confidentially and in compliance with organizational policies and relevant laws.
Liaise with investigation teams, compliance officers, legal counsel, vendors, segment General Managers, and other relevant stakeholders to coordinate follow-up actions and tailor strategies for each business line.
Facilitate communication between whistleblowers, complainants, investigative bodies, vendors, GMs, and multiple departments, ensuring clarity and timely responses.
Track the progress and outcomes of referred cases, providing regular status updates as appropriate.
Identify trends, patterns, and potential systemic issues through analysis of reported FWA cases.
Prepare reports and present findings to management, compliance committees, or regulatory agencies as necessary.
Master and adapt healthcare fraud shield systems to optimize detection of FWA in both pre-payment and post-payment scenarios, customizing these tools for each line of business in collaboration with segment GMs.
Support training and awareness initiatives related to fraud, waste, and abuse prevention.
Assist in the development and continuous improvement of protocols for FWA detection and response, ensuring these protocols meet the specific needs of each segment.
Multitask and collaborate effectively with multiple departments to support organizational goals and ensure seamless operations.
Hybrid or onsite work environment depending on organizational needs.
Occasional travel may be required for training, meetings, or casework.
Position may entail handling sensitive or distressing information.
The position has an onsite expectation of 1 day per week and requires a full-time work schedule.
Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
This role will also function as a backup for the Fraud, Waste, Abuse Reporting Analyst position, providing coverage during absences, vacations, or other times when support is required.
Perform all other duties as assigned.