Fraud Analyst / Healthcare Domain

Summary:

Validate whether the FWA detection approach surfaces real, actionable fraud/waste/abuse signal, and produce substantiated findings to support FWA product development.

Responsibilities:

• Review claims flagged by detection logic and determine true positive vs. false positive
• Articulate the specific billing pattern, code combination, or provider behavior driving each call
• Carry select flagged leads through to a documented, substantiated finding
• Partner with product and data science teams to translate investigative judgment into refined detection rules
• Track progress against substantiation-rate and findings-volume targets (set once POC window and initial data are confirmed)
• Write a findings/recommendation memo scale, iterate, or kill for internal stakeholders
• Present findings clearly to non-investigator audiences (product, compliance, leadership)

Skills & Qualifications:

• 4+ years FWA investigative experience, payer-side preferred
• Direct exposure to claims coding logic (CPT/HCPCS, ICD-10, DRG/APC)
• Must have prior experience starting cold on a live data feed
• Comfortable working from partial/imperfect data sample extracts, not a finished production system
• Certification required: AHFI, CFE, or CPC/CPMA
• SQL or equivalent self-serve query ability
• Familiarity with edit/rules logic (e.g., NCCI edits)

Education:

• Bachelor's degree, or 7+ years relevant experience in lieu