Claims Fraud Analyst Job at Best Doctors Insurance, Miami, FL

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  • Best Doctors Insurance
  • Miami, FL

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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