We are actively seeking a Fraud, Waste, & Abuse Specialist! The Fraud, Waste, and Abuse (FWA) Specialist is responsible for the day-to-day execution of our enhanced claim control strategies. The Specialist is on the front line of GeoBlue’s efforts to reduce unnecessary medical spending and make healthcare more affordable for everyone. The primary responsibility will be to evaluate claim submissions for evidence of fraud, waste, or abuse using an ever-increasing set of tools and techniques, none more important than good judgement and creative problem solving.
- Evaluate claims and determine the most appropriate remedy for preventing fraud, waste, or abuse, if applicable.
- Contact external 3rd parties through outbound call or email to verify claim information.
- Negotiate high-cost claims with non-contracted providers.
- Validate accuracy of claim charges and initial processing decisions.
- Coordinate activities across other departments (ex., Clinical, Provider Finance, Global Service Center, Claims) and external entities (ex., home plans).
- Determine if claim costs are Usual, Customary, and Reasonable through comparative analysis with historic claims.
- Perform online research to fill in gaps in existing tools and understanding.
- Attempt to obtain written confirmation of falsified claims through independent investigation and recorded interviews/interrogations.
- Perform analysis on historic claims to determine the full scope of identified fraudulent activity.
- Track activity and produce reports to measure impact and document actions.
- Other duties as assigned.
- Bachelor’s degree or equivalent experience required; advanced degree or certification valued.
- Minimum of 3 years insurance industry experience required; 5-10 preferred.
- Strong attention to detail and problem-solving skills.
- Strong working knowledge of international health insurance claims.
- Knowledge of US Domestic health insurance claims is a plus.
- Previous experience navigating GeoBlue’s various claim systems is a significant plus.
- Prior experience identifying or investigating fraud, waste, and abuse is not required, but is highly valued.
- Excellent written and verbal communication skills.
- Strong organizational skills, with the ability to manage multiple competing tasks at the same time.
- Ability to manage ambiguity and drive for resolution.
- Willingness and ability to learn and apply new skills.
- Multilingual strongly preferred.
- Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).
- Flexibility to work in an office and/or at-home, remote office environment.
- Schedule flexibility is occasionally necessary in this position. Individual may be required to attend key business/departmental meetings and/or perform certain business critical job functions outside of normal working hours.
- Physical Demands: Must be able to communicate internally and externally through receiving and responding to auditory and visual methods.
Internal Pay Grade: 8
The starting pay for this role is $50,921 to $63,651 based on skill level and experience in a similar role.
This job description reflects management’s assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned.