Elite Technical is seeking a Fraud, Waste and Abuse Analyst to support our client, a major healthcare insurance organization in the Maryland area. Our client is seeking six analysts (2 hybrid in MD, 4 remote within the EST timezone) to support their Special Investigations Unit (SIU). The selected candidates will assist the investigation team with preliminary documentation gathering and analysis of any membership enrollment fraud activities. The selected candidate will assist in the reduction and recuperation of losses through the detection, investigation, and resolution of low to medium levels fraud, waste, and abuse schemes, resulting in the savings and recovery of funds. Responsibilities include:

-Independently conduct low to medium level investigations and provide support as part of an assigned team to all levels (low to medium) investigations of suspected fraud, waste, and abuse. In conjunction with assigned team or management, develop and execute investigative plans that may include performance of audits of financial business records, provider and subscriber medical data, claims, systems--'--"- reports, medical records, analysis of contract documents, provider/subscriber claims history, benefits, external data banks and other documents to determine the possible existence of fraud and/or abuse.
-Research provider/subscriber claims activity, operations manuals, data systems, medical policies, job duties and group benefit contracts to identify control deficiencies and non-compliance. Investigator will develop documentation to substantiate finding including formal reports, spreadsheets, graphs, audit logs, use of anti-fraud software and appropriately sourced reference materials. Must ensure audits and investigations are timely, effective and result in an overall achievement of unit goals.
-Initiate claim adjustments, voucher deducts, and voluntary refunds in order to recover funds. Record recoveries and savings following established processes.

Want to learn more? Then you should contact Elite Technical right away for consideration!

Required Skills

-Education Level: Bachelor's Degree. In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
-Experience: 3+ years of experience in an analytical or investigative position, ideally within the healthcare insurance or healthcare industry.
- Excellent communication skills both written and verbal
- Ability to recognize, analyze, and solve a variety of problems. Must have outstanding research abilities.
- MS Office (Word, Excel and Outlook) is required

Preferred:
- Working experience in the healthcare sector within a Fraud, Waste and Abuse sector.
-Certifications: Certified Fraud Examiner (CFE), Accredited Health Fraud Investigator (AHFI), RN/LPN, or Certified Professional Coder (CPC).
-Knowledge of ICD 10 and CPT---- Codes, medical terminology, extensive training in claims and subscriber customer service methods, and previous experience in the health care industry.
-Knowledge of laws that pertain to public and insurance funds