Point32Health is currently seeking highly motivated individuals to join our organization as an Fraud Analyst within our Special Investigations Unit ( SIU ). The Fraud Analyst is an essential team member of the SIU, responsible for analyzing claim trends, patterns and outliers, developing and refining queries to detect potentially fraudulent claim submissions and performing initial background investigations on newly identified leads.
- Developing and running periodic health insurance claims queries / extracts to identify potentially fraudulent claim submissions or patterns.
- Enhancing existing analytics and data-mining capabilities by partnering with management of the Analytics & Triage team to develop and refine processes to identify potential fraud, waste & abuse.
- Performing background research on newly identified case leads, including vetting referrals submitted through the plan's dedicated Fraud, Waste & Abuse hotline and e-mail box.
- Performing pre-payment review activity on flagged claims, including requesting records, seeking clinical review, and issuing letters back to submitting providers.
- Corresponding with various business units throughout the organization to understand various aspects of the health insurance reimbursement process including contract, payment, authorization and appeal divisions, among others.
- Other duties and projects as assigned.
EDUCATION, CERTIFICATION AND LICENSURE:
- Bachelor's degree, preferably in, computer science, statistics or criminal justice.
- Certified Fraud Examiner ( CFE ), Accredited Health Care Fraud Investigator ( AHFI ) or similar designation a plus.
EXPERIENCE (minimum years required):
- 3+ years related experience in health insurance, analytics or fraud investigations (Will consider an equivalent combination of experience and education).
- Proficiency in SQL (Teradata, Oracle, SQL Server) and SAS (can train the right candidate).
- Experience with R and Python (PySpark) a plus.
- Experience with Tableau and/or other data visualization tools a plus
- Ability to produce clear, concise, and well-organized documents.
- Resilient, collaborative, flexible, innovative.
What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!
Please note: As of Nov. 1, 2021, full vaccination against COVID-19 is required to enter any Point32Health office or if, on behalf of Point32Health, you are meeting in-person with individuals outside of a Point32Health office. As of Dec. 8, 2021, all employees - including remote employees - must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.
Point32Health is a leading health and wellbeing organization, delivering an ever-better health care experience to everyone in our communities. Building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.
At Point32Health, we're working to reshape the world of health care by pushing past the status quo and delivering even more to the diverse communities we serve: more innovation, more access, more support, and healthier lives. And we want people like you on our side to make it even better.
This job has been posted by TalentBoost on behalf of Point32Health. TalentBoost is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of TalentBoost not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.
Req ID: R2991