Investigative Analyst – CMS Healthcare Claims

This is a fully remote position, open to applicants in United States.

📋 Description

• Execute analytical tasks that support the HFPP program.

• Detect referrals and leads related to fraud, waste, and abuse from HFPP Analytics.

• Perform data mining across the partnership utilizing internal tools.

• Collaborate on analytic reports for the HFPP.

• Create fraud, waste, and abuse referrals and leads for Partners based on analytic insights.

• Propel outcome metrics concerning referrals and leads communicated with Partners.

• Regularly engage with Partners about identified referrals and leads.

• Assist in business development efforts, which includes analyzing health claims data, producing study referrals and leads, creating provider background profiles, and pinpointing opportunities for meetings with Partners.

• Aid CMS and the Trusted Third Party in mitigating healthcare fraud, waste, and abuse.

⛳️ Requirements

• BA/BS degree or equivalent experience.

• Over 8 years of experience in health care claims analysis.

• Excellent oral and written communication skills, capable of presenting to management-level personnel.

• Proficient in the Microsoft Office suite.

• Familiarity with Tableau, Amazon WorkSpaces, Jira, and Confluence.

• Understanding of HIPAA privacy and security regulations.

• Strong decision-making, organizational, prioritization, and interpersonal abilities.

• Capacity to independently resolve issues.

• Ability to manage complex projects with general direction and minimal supervision.

• Competence to work effectively both independently and within a team setting.

• Sponsorship for work visas will not be available.

• Certification as a Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) is highly desired.

• Certified clinical coding is preferred.

🏝️ Benefits

• A comprehensive range of medical plan options, including those with Health Savings Accounts.

• Various dental plan options.

• Vision insurance coverage.

• 401(k) plan with company matching contributions.

• Flexible work weeks.

• Paid time off, which includes vacation, sick leave, personal days, holidays, parental leave, military leave, bereavement leave, and jury duty leave.

• Typically, 15 days of paid leave each calendar year.

• Ten paid holidays annually.

• Up to 160 hours of paid family leave within a rolling 12-month period for eligible employees.

• Short-term and long-term disability benefits.

• Life insurance coverage.

• Accidental death and dismemberment insurance.

• Personal accident insurance.

• Critical illness insurance.

• Business travel and accident insurance.

• A growth tool that identifies career steps and learning opportunities.

• Support for internal mobility.

• Wellness packages offered.

• An award-winning culture that fosters innovation.

• A military-friendly workplace.