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Avesis is looking for a Fraud, Waste and Abuse Program Integrity Business Analyst for our dental and vision provider network. This position is responsible for assisting in provider investigations and reporting to ensure the prevention of healthcare fraud, waste and abuse. The business analyst will also be responsible for building workflow and processes within the program integrity function, including; but not limited to; investigative milestones, reporting, overpayment recoveries and federal database exclusion reporting and monitoring. The business analyst will assist in analyzing claims data reports and dashboards, applicable provider guidelines, and other pertinent sources of information to identify aberrant provider billing practices and patterns. The business analyst will also assist in specific program integrity/compliance projects as needed, such as implementation of new contracts for fraud, waste, and abuse activities and requests for information from various sources within the company.
Essential functions:
- Interpret data analytic trending reports and identify aberrant dental and vision providers, including advanced excel skills to drill down on outliers
- Ability to work independently and make informed decisions regarding workflows and other program integrity investigative milestones
- Understand state and federal regulations regarding program integrity (Medicare and Medicaid)
- Ability to read and understand contract language and contractual obligations in relation to program integrity
- Understand managed care/insurance regulations in relation to FWA investigations
- Demonstrate presentation skills and ability to formulate power point presentations to present program integrity topics to both internal and external sources
- Ability to work in several different tracking systems, including credentialing, National Practitioner DataBase, claims systems, and other systems as needed to assist in program integrity operations
- Ability to assist in organizing and developing processes within FWA to increase efficiency (both dental and vision programs)
Primary Responsibilities:
- Assist in specific investigative tasks related to fraud, waste and abuse of both vision and dental investigations
- Develop and deploy effective workflow processes in relation to program integrity state and federal requirements
- Assist in maintaining and accurate and organized case tracking system for all dental and vision provider fraud, waste, and abuse investigations
- Communicating effectively with providers in relation to open investigations or other fraud, waste, and abuse issues
- Assist in creation of new policies, procedures, letter templates and forms as needed by program integrity department
- Accurately track overpayment recoveries, document and work with collection agency to collect with necessary
- Collect, collate, analyze, and interpret data relating to fraud, waste, and abuse referrals
- Ensure compliance of applicable federal/state regulations or contractual obligations
- Completing, tracking and organizing all program integrity reporting requirements for all current and future contracts/plans.
- Comply with goals, policies, procedures, and strategic plans as delegated by leadership
- Collaborate with state/federal partners, at the discretion of leadership, to include attendance at workgroups or regulatory meetings
- Other business analyst functions/duties as needed
Requirements:
- Bachelor's Degree OR 5+ years of experience in healthcare program integrity or fraud, waste, and abuse investigations.
- Intermediate level of proficiency in Microsoft Excel and Word
- 1+ years of experience in state and federal regulatory FWA requirements
- 1+ years of experience with local, state/federal laws and regulations pertaining to program integrity and/or healthcare fraud, waste and abuse (FWA)
- 1+ years of experience with Compliance Program policies, procedures and documentation standards
- Vision and/or dental office experience, i.e. coding/billing/office staff preferred but not required
- Knowledge of dental and vision CPT, ICD-10 and HCPCS codes preferred but not required
Preferred active affiliations:
- National Health Care Anti-Fraud Association (NHCAA)
- Accredited Health Care Fraud Investigator (AHFI)
- Certified Fraud Examiner (CFE)
- Certified Professional Coder (CPC)
FLSA Status: Salary/Exempt
National Salary Range: $55,790 - $87,230
How to stay safe:
Avesis is aware of fraudulent activity by individuals falsely representing themselves as Avesis recruiters. In some instances, these individuals may even contact applicants with a job offer letter, ask applicants to make purchases (i.e., a laptop or gift cards) from a designated vendor, have applicants fill out W-2 forms, or ask that applicants ship or send packages of goods to the company.
Avesis would never make such requests to applicants at any time throughout our job application process. We also would never ask applicants for personal information, such as passport numbers, bank account numbers, or social security numbers, during process. Our recruitment process takes place by phone and via trusted business communication platform (i.e., Zoom, Webex, Microsoft Teams, etc.). Any emails from Avesis recruiters will come from a verified email address ending in @Avesis.com.
We urge all applicants to exercise caution. If something feels off about your interactions, we encourage you to suspend or cease communications. If you are unsure of the legitimacy of a communication you have received, please reach out to ITsupport@Avesis.com.
To learn more about protecting yourself from fraudulent activity, please refer to this article link (https://consumer.ftc.gov/articles/how-avoid-scam). If you believe you were a victim of fraudulent activity, please contact your local authorities or file a complaint (Link: https://reportfraud.ftc.gov/#/) with the Federal Trade Commission. Avesis is not responsible for any claims, losses, damages, or expenses resulting from unaffiliated individuals of the company or their fraudulent activity.
We Offer
- Meaningful and challenging work opportunities to accelerate innovation in a secure and compliant way.
- Competitive compensation package.
- Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period.
- Life and disability insurance.
- A great 401(k) with company match.
- Tuition assistance, paid parental leave and backup family care.
- Dynamic, modern work environments that promote collaboration and creativity to develop and empower talent.
- Flexible time off, dress code, and work location policies to balance your work and life in the ways that suit you best.
- Employee Resource Groups that advocate for inclusion and diversity in all that we do.
- Social responsibility in all aspects of our work. We volunteer within our local communities, create educational alliances with colleges, drive a variety of initiatives in sustainability.
Equal Employment Opportunity
At Avēsis, We See You. We celebrate differences and are building a culture of inclusivity and diversity. We are proud to be an Equal Employment Opportunity employer that considers all qualified applicants and does not discriminate against any person based on ancestry, age, citizenship, color, creed, disability, familial status, gender, gender expression, gender identity, marital status, military or veteran status, national origin, race, religion, sexual orientation, or any other characteristic. At Avēsis, we believe that, to operate at the peak of excellence, our workforce needs to represent a rich mixture of diverse people, all focused on providing a world-class experience for our clients. We focus on recruiting, training and retaining those individuals that share similar goals. Come Dare to be Different at Avēsis, where We See You!
