Job Description

Position Overview

We are seeking a diligent and skilled Claims Fraud Waste and Abuse Analyst to join our team at Best Doctors Insurance, a leading International private medical insurance provider. The successful candidate will play a crucial role in ensuring the integrity of claims payments, identifying potential fraud, waste, and abuse, and maintaining high standards of accuracy and compliance in health insurance claims processing.

Key Responsibilities

• Analyze health insurance claims to identify potential fraud, waste, and abuse.
• Investigate claims payment integrity and ensure compliance with industry standards.
• Audit medical claims for irregular billing codes, including upcoding, unbundling, etc.
• Perform data mining on claims data to identify aberrant coding trends and potential fraud.
• Utilize CPT, HCPCS, and ICD-10 codes effectively in auditing and analysis.
• Prepare detailed reports and recommendations based on findings.
• Collaborate with other departments to ensure comprehensive fraud prevention strategies.
• Maintain up-to-date knowledge of industry trends and regulatory changes.

Key Skills and Qualifications

• Attention to Detail: Meticulous approach to scrutinizing claims and identifying discrepancies.
• Knowledge in Health Insurance Claims: Proficient understanding of claims processing and payment integrity.
• Critical Eye: Ability to critically evaluate claims data to detect potential fraud.
• Bilingual (Spanish and English): Fluency in both languages is required. Portuguese proficiency is preferred.
• Experience Investigating Claims Payment Integrity: Proven track record in ensuring accurate claims payments.
• Understanding of CPT, HCPCS, and ICD-10: Thorough knowledge of coding standards and practices.
• Experience Auditing Medical Claims: Skilled in identifying irregular billing practices.
• Data Mining: Expertise in analyzing claims data to uncover trends indicative of fraud, waste, and abuse.
• MS Excel: Proficient in intermediate-level Excel functions for data analysis and reporting.

Preferred Qualifications

• Additional proficiency in Portuguese.
• Experience working in an international insurance environment.
• Advanced certification in fraud detection or healthcare auditing.

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