FWA - Fraud Waste and Abuse Auditor - hybrid MD

Yoh; Texas; On-site; USD 63,000 - 90,000; Full time

Benefits offered by this job

Medical benefits (employee)

Health Savings Account

Life & Disability Insurance

MetLife voluntary benefits

Employee Assistance Program (EAP)

401K Retirement Savings Plan

Direct Deposit & weekly epayroll

Referral bonus programs

Certification and training

Job summary

Yoh Services LLC in Bowie, MD seeks an experienced FWA investigator to validate detection signals and produce substantiated findings to support fraud, waste, and abuse (FWA) product development.

Responsibilities include reviewing claims flagged by detection logic, detailing billing patterns driving each case, advancing selects to substantiated findings, and collaborating with product and data science to refine rules. On-site three days per week in Bowie.

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)

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

FWA investigator experience

CPC/CPMA

AHFI/CFE/CPC/CPMA

CPT/HCPCS knowledge

ICD-10 knowledge

DRG/APC knowledge

SQL

NCCI edits familiarity

Education

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

Job description

• CPC/CPMA required
• Nov 16th to Feb 8th might extend
• Fraud Waste Abuse exp
• Commercial Medicare/ Medicaid
• on site Bowie MD 3 days a week
• SQL exp
• Exp with Health plans

Person needs to review current work

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

Estimated Min Rate: $45.50

Estimated Max Rate: $65.00

What's In It for You?

We welcome you to be a part of the largest and legendary global staffing companies to meet your career aspirations. Yoh's network of client companies has been employing professionals like you for over 65 years in the U.S., UK and Canada. Join Yoh's extensive talent community that will provide you with access to Yoh's vast network of opportunities and gain access to this exclusive opportunity available to you.

Benefit eligibility is in accordance with applicable laws and client requirements. Benefits include:

• Medical, Prescription, Dental & Vision Benefits (for employees working 20+ hours per week)
• Health Savings Account (HSA) (for employees working 20+ hours per week)
• Life & Disability Insurance (for employees working 20+ hours per week)
• MetLife Voluntary Benefits
• Employee Assistance Program (EAP)
• 401K Retirement Savings Plan
• Direct Deposit & weekly epayroll
• Referral Bonus Programs
• Certification and training opportunities

Note: Any pay ranges displayed are estimations. Actual pay is determined by an applicant's experience, technical expertise, and other qualifications as listed in the job description.

Yoh, a Day & Zimmermann company, is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

For California applicants, qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. All of the material job duties described in this posting are job duties for which a criminal history may have a direct, adverse, and negative relationship potentially resulting in the withdrawal of a conditional offer of employment.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.