Fraud, Waste, and Abuse (FWA) Product and Analytics Subject Matter Expert (SME)

Hcfraudshield; Chesterfield (MO); Remote; USD 75,000 - 115,000; Full time

Job summary

Healthcare Fraud Shield is seeking a Subject Matter Expert (SME) in Healthcare Fraud, Waste, and Abuse (FWA) to provide data analytics and product innovation expertise. The role focuses on identifying and preventing fraud, enhancing product solutions, and collaborating with teams while ensuring compliance with healthcare regulations.

Benefits

Medical, Dental & Vision insurance

401(k) retirement savings with employer match

Vacation and sick paid time off

8 paid holidays

Paid maternity/paternity leave

Disability & Life insurance

Flexible Spending Account (FSA)

Employee Assistance Program (EAP)

Professional and career development initiatives

Remote work eligible

Qualifications

• Extensive experience in healthcare fraud detection and intervention required.
• Strong understanding of healthcare benefit structures and claim processing.
• Excellent communication skills to convey complex concepts.

Responsibilities

• Provide expert guidance on healthcare fraud detection and prevention.
• Perform complex data analysis and validate results on potential fraud.
• Collaborate with teams for product development and fraud analytics.

Skills

Data Analytics

Healthcare Fraud Detection

Regulatory Compliance

Machine Learning

Statistical Analysis

Education

Bachelor's degree in Healthcare, Data Analytics, or Criminal Justice

Tools

Data Analytics Tools

ICD-10

CPT

HCPCS

Job description

Fraud, Waste, and Abuse (FWA) Product and Analytics Subject Matter Expert (SME)

Department: SIU

Employment Type: Full Time

Location: Headquarters

Description

Healthcare Fraud Shield is seeking a skilled Subject Matter Expert (SME) in Healthcare Fraud, Waste, and Abuse (FWA) to assist with data analytics and product innovation. The role uses expertise in healthcare policy and regulations, medical claims analysis, along with advanced analytical techniques, to identify, prevent, and mitigate fraud, waste, and abuse within healthcare programs. The SME also provides feedback and enhances FWA-related products and solutions.

Key Responsibilities

• Subject Matter Expertise:
  • Provide expert guidance on healthcare FWA, including fraudulent billing practices, emerging schemes, and regulatory compliance.
  • Interpret and apply healthcare policies, regulations, and industry best practices related to FWA detection and prevention.
  • Understands FWA software solutions to assist in the detection, prevention and tracking of FWA audits and cases.
  • Understands and complies with all company Privacy and Security standards.
• Data Analytics & Investigations:
  • Validating results and performing complex data analysis on patterns, trends, and anomalies indicative of potential fraud.
  • Develop, test and apply advanced analytical techniques, including predictive modeling, behavioral analysis, and machine learning, to detect and prevent fraud.
  • Collaborate with data scientists and analysts to support the implementation and enhancement of fraud analytics solutions.
• Product Innovation & Development:
  • Identify and assess FWA product and service opportunities.
  • Contribute to defining the FWA product strategy and roadmap, ensuring competitiveness in the marketplace.
  • Support the development and enhancement of FWA detection and prevention products and solutions.
  • Provide fraud insights to product management teams to integrate fraud prevention into product design.
• Collaboration & Communication:
  • Collaborate with cross-functional teams, including product management, data science, compliance, and investigative resources.
  • Communicate findings and recommendations effectively to stakeholders, including administrative and business leaders.
  • Provide training and guidance to internal teams on fraud detection best practices and prevention strategies.

Skills, Knowledge and Expertise

• AHFI and/or CPC preferred.
• A Bachelor's degree in a relevant field such as healthcare, data analytics, or criminal justice.
• Extensive experience in healthcare fraud detection, investigation, and intervention.
• Demonstrated expertise in data analytics, including the use of data analytics tools and methodologies to identify and analyze fraudulent patterns.
• Knowledge of various data analytics algorithms and techniques, including predictive modeling, machine learning, and data mining.
• Experience with medical claims coding systems (e.g., ICD-10, CPT, HCPCS).
• A strong understanding of healthcare benefit structures and claim processing systems.
• Excellent communication and interpersonal skills, with the ability to effectively communicate complex technical concepts to diverse audiences.

Benefits

• Medical, Dental & Vision insurance
• 401(k) retirement savings with employer match
• Vacation and sick paid time off
• 8 paid holidays
• Paid maternity/paternity leave
• Disability & Life insurance
• Flexible Spending Account (FSA)
• Employee Assistance Program (EAP)
• Professional and career development initiatives
• Remote work eligible

REMOTE WORK REQUIREMENTS

• Must have high speed Internet (satellite is not allowed for this role) with a minimum speed of 25mbs download and 5mbs upload.

Healthcare Fraud Shield is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.