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
Rate:
Not specified
Location:
Remote
IR35 Status:
Outside
Remote Status:
Remote
Industry:
Data & Analytics
Seniority Level:
Mid-Level