The Health Plan (THP)
SIU Fraud Analytics Specialist
The Health Plan (THP), Wheeling, West Virginia, United States, 26003
The SIU Fraud Analytics Specialist is a key member of a team dedicated to the prevention, detection, investigation, and reporting of healthcare fraud, waste, and abuse (FWA), program integrity initiatives, and the recovery of overpayments in a multi-payer environment. This data-intensive role blends analytical expertise with investigative coordination to support and enhance Special Investigations Unit (SIU) operations.
The Specialist is responsible for leveraging advanced data mining and analytical tools to identify outliers, aberrant billing patterns, potential FWA, and payment vulnerabilities. They proactively generate investigative leads and conduct thorough reviews of payment integrity matters, including those where fraud is not suspected, ensuring an ethical and comprehensive investigation is completed.
In addition to analytical duties, the Specialist serves as the SIU’s Law Enforcement Liaison, coordinating and fulfilling data requests and analytics for external entities such as the West Virginia Medicaid Fraud Control Unit (MFCU), the West Virginia Offices of the Insurance Commissioner (WVOIC), the Office of the Inspector General (ODI), the United States Attorney’s Office (USAO), and other regulatory or law enforcement bodies.
The Specialist also plays a critical role in investigative intake and coordination, which may include screening and triaging incoming complaints, preparing cases for investigator review, tracking statistics, and compiling internal reports for other departments.
Requirements
EDUCATION: Associate's degree in any field, with preference for degree in Criminal Justice, Data Analytics, Health Informatics, Health Information Management, or related field. (Two [2] years of relevant experience as described below in QUALIFICATIONS DESIRED section may be substituted for the required education.) EXPERIENCE: At least 1 year of experience working with Microsoft Excel in a professional environment. Advanced proficiency in Microsoft Excel; basic proficiency in Word, Outlook and other common programs. Strong organizational and analytical skills. Detail oriented, with a high level of accuracy. Effective written and oral communication skills. Ability to plan and execute projects independently and meet tight deadlines. Preferred Qualifications
Education: Bachelor's degree in Accounting, Business, Criminal Justice, Data Analytics, Health Informatics, Health Information Management, or related field; or a Bachelor's degree in any field and a Master's Degree in any fraud-related discipline. At least 2 years of relevant experience such as: SIU, healthcare fraud investigation, medical claim investigation, healthcare program integrity, data mining or analytics, healthcare claims payment processing, clinical experience, compliance, or certification as AHFI, CPC/CCP/CCS/CMC, or CFE. Proficiency in fraud analytics. Advanced technical skills related to data mining and analysis of healthcare claims data. Experience with SQL/Microsoft Report Builder and Report Manager. Experience in Medical Terminology and/or Coding. Experience in a federally regulated environment such as Medicaid or Medicare Advantage. Responsibilities
Monitoring/attending to various FWA allegation reporting tools such as: THP fraud hotline, THP FWA Web Portal, SIU/QI Form Submissions. Gathering preliminary information on all incoming allegation referrals and preparing them for SIU review, to ensure timely and proper assignment or disposition. Entering cases into the case management and tracking system and analyzing healthcare claims data and other relevant information reactively, in response to allegations of FWA, to ascertain potential exposure. Leveraging analytic tools to provide in-depth data analysis in support of fraud investigations and payment integrity activities; Conducting strategic analysis of healthcare claims data from initial data scoping through transformation and validation, and conveying results in verbal, written, and visual formats; Analyzing healthcare claims data and other relevant information reactively, in response to allegations of FWA, and proactively, to identify trends and patterns indicative of FWA; Utilizing fraud detection software and large data sets to identify outliers and inform decision-making related to FWA investigations and the identification and recovery of overpayments; Obtaining, cleaning, normalizing, and validating healthcare claims data for the purposes of supporting FWA investigations and informing investigative and recovery decisions; Drafting clear and concise, yet appropriately detailed reports of findings which may include recommendations related to case disposition, corrective actions, and/or process improvements; Analyzing and synthesizing information from multiple sources including claims data, contracts, enrollment data, provider manuals, educational materials, bulletins, and state and federal regulations, to determine impact on claims payment as it relates to SIU cases or leads; Responding to requests for information from various sources, including Medicaid, I-MEDIC, MFCU, and the WV OIC; Expertise in the use of fraud detection software and case tracking system; Creating and delivering training on databases, analytics software, and other relevant systems and techniques; Identifying and recommending process improvements to reduce FWA; Tracking, trending, and reporting identified metrics, including dashboard reporting; Maintaining technical knowledge and skills by attending professional conferences and trainings, obtaining or retaining professional certification(s), and pursuing constant learning through membership in relevant professional organizations; Investigating matters of payment integrity as assigned by the FWA Data Analytics Manager.
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EDUCATION: Associate's degree in any field, with preference for degree in Criminal Justice, Data Analytics, Health Informatics, Health Information Management, or related field. (Two [2] years of relevant experience as described below in QUALIFICATIONS DESIRED section may be substituted for the required education.) EXPERIENCE: At least 1 year of experience working with Microsoft Excel in a professional environment. Advanced proficiency in Microsoft Excel; basic proficiency in Word, Outlook and other common programs. Strong organizational and analytical skills. Detail oriented, with a high level of accuracy. Effective written and oral communication skills. Ability to plan and execute projects independently and meet tight deadlines. Preferred Qualifications
Education: Bachelor's degree in Accounting, Business, Criminal Justice, Data Analytics, Health Informatics, Health Information Management, or related field; or a Bachelor's degree in any field and a Master's Degree in any fraud-related discipline. At least 2 years of relevant experience such as: SIU, healthcare fraud investigation, medical claim investigation, healthcare program integrity, data mining or analytics, healthcare claims payment processing, clinical experience, compliance, or certification as AHFI, CPC/CCP/CCS/CMC, or CFE. Proficiency in fraud analytics. Advanced technical skills related to data mining and analysis of healthcare claims data. Experience with SQL/Microsoft Report Builder and Report Manager. Experience in Medical Terminology and/or Coding. Experience in a federally regulated environment such as Medicaid or Medicare Advantage. Responsibilities
Monitoring/attending to various FWA allegation reporting tools such as: THP fraud hotline, THP FWA Web Portal, SIU/QI Form Submissions. Gathering preliminary information on all incoming allegation referrals and preparing them for SIU review, to ensure timely and proper assignment or disposition. Entering cases into the case management and tracking system and analyzing healthcare claims data and other relevant information reactively, in response to allegations of FWA, to ascertain potential exposure. Leveraging analytic tools to provide in-depth data analysis in support of fraud investigations and payment integrity activities; Conducting strategic analysis of healthcare claims data from initial data scoping through transformation and validation, and conveying results in verbal, written, and visual formats; Analyzing healthcare claims data and other relevant information reactively, in response to allegations of FWA, and proactively, to identify trends and patterns indicative of FWA; Utilizing fraud detection software and large data sets to identify outliers and inform decision-making related to FWA investigations and the identification and recovery of overpayments; Obtaining, cleaning, normalizing, and validating healthcare claims data for the purposes of supporting FWA investigations and informing investigative and recovery decisions; Drafting clear and concise, yet appropriately detailed reports of findings which may include recommendations related to case disposition, corrective actions, and/or process improvements; Analyzing and synthesizing information from multiple sources including claims data, contracts, enrollment data, provider manuals, educational materials, bulletins, and state and federal regulations, to determine impact on claims payment as it relates to SIU cases or leads; Responding to requests for information from various sources, including Medicaid, I-MEDIC, MFCU, and the WV OIC; Expertise in the use of fraud detection software and case tracking system; Creating and delivering training on databases, analytics software, and other relevant systems and techniques; Identifying and recommending process improvements to reduce FWA; Tracking, trending, and reporting identified metrics, including dashboard reporting; Maintaining technical knowledge and skills by attending professional conferences and trainings, obtaining or retaining professional certification(s), and pursuing constant learning through membership in relevant professional organizations; Investigating matters of payment integrity as assigned by the FWA Data Analytics Manager.
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