Doctorshcp
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Analyst - Fraud, Waste & Abuse
role at
Doctors HealthCare Plans, Inc.
Position Purpose: The Analyst – Fraud, Waste & Abuse (FWA) provides leadership in the investigation of potential FWA cases; its main goal is to detect and prevent fraud, waste, and abuse.
Key Responsibilities
Conduct in-depth investigations of potential FWA cases using monitoring, audits, forensic analysis, and interviews; as well as external platforms and guidelines (CMS, state and federal guidelines, etc.)
Analyze large datasets to identify patterns, trends, and anomalies indicative of FWA activity
Develop strategies to mitigate fraud risk and ensure compliance with regulatory requirements
Maintain process integrity and ensure legitimate claims are processed efficiently
Implement and track corrective action plans
Prevent fraud and educate employees and members on fraud detection and reporting
Document Special Investigations, FWA and Payment Integrity monitoring activities
Collaborate with other departments such as Claims, Medical Management, Internal Audit, Recovery and Legal teams
Support litigation and legal defense by providing evidence to support claim denials or fraud prosecutions
Work with law enforcement and regulators to report fraud cases to I-MEDIC, RPC, AHCA, and other regulators and authorities
Perform monthly audit for excluded/precluded providers
Develop CMS HPMS and AHCA-MPI memos related to sanctioned providers
Develop member complaints received by Member Services for potential FWA
Meet performance goals and metrics established for the position
Perform additional duties and responsibilities as assigned by management
Qualifications
Minimum of 5 years of FWA, healthcare and/or Medicare Advantage experience
Strong knowledge of Medicare Advantage, CMS and AHCA regulatory requirements
Expertise in FWA, Special Investigations and claims processing
Outstanding research and investigative skills
Proven track record in operations and process improvement
Able to thrive in a complex, high‑pressure environment
Bachelor’s degree in Business, Healthcare Administration or related field
High‑degree of computer literacy and well‑versed in Excel
Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all inclusive or specific to any individual team member.
Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
Miami, FL
#J-18808-Ljbffr
Analyst - Fraud, Waste & Abuse
role at
Doctors HealthCare Plans, Inc.
Position Purpose: The Analyst – Fraud, Waste & Abuse (FWA) provides leadership in the investigation of potential FWA cases; its main goal is to detect and prevent fraud, waste, and abuse.
Key Responsibilities
Conduct in-depth investigations of potential FWA cases using monitoring, audits, forensic analysis, and interviews; as well as external platforms and guidelines (CMS, state and federal guidelines, etc.)
Analyze large datasets to identify patterns, trends, and anomalies indicative of FWA activity
Develop strategies to mitigate fraud risk and ensure compliance with regulatory requirements
Maintain process integrity and ensure legitimate claims are processed efficiently
Implement and track corrective action plans
Prevent fraud and educate employees and members on fraud detection and reporting
Document Special Investigations, FWA and Payment Integrity monitoring activities
Collaborate with other departments such as Claims, Medical Management, Internal Audit, Recovery and Legal teams
Support litigation and legal defense by providing evidence to support claim denials or fraud prosecutions
Work with law enforcement and regulators to report fraud cases to I-MEDIC, RPC, AHCA, and other regulators and authorities
Perform monthly audit for excluded/precluded providers
Develop CMS HPMS and AHCA-MPI memos related to sanctioned providers
Develop member complaints received by Member Services for potential FWA
Meet performance goals and metrics established for the position
Perform additional duties and responsibilities as assigned by management
Qualifications
Minimum of 5 years of FWA, healthcare and/or Medicare Advantage experience
Strong knowledge of Medicare Advantage, CMS and AHCA regulatory requirements
Expertise in FWA, Special Investigations and claims processing
Outstanding research and investigative skills
Proven track record in operations and process improvement
Able to thrive in a complex, high‑pressure environment
Bachelor’s degree in Business, Healthcare Administration or related field
High‑degree of computer literacy and well‑versed in Excel
Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all inclusive or specific to any individual team member.
Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
Miami, FL
#J-18808-Ljbffr