Senior Healthcare Fraud Analyst

<strong>At CNSI, we strive to be the market leader and most trusted partner for innovative and transformative technology-enabled solutions that improve health outcomes and reduce costs. We&rsquo;re passionate about helping our clients improve the health and well-being of individuals and families. We succeed when our clients succeed.</strong>

Rockville, MD


<strong>CNSI delivers a broad range of health information technology enterprise solutions and customizable products to a diverse base of state and federal agencies. We align, build, and manage innovative, high-quality, cost-effective solutions that help customers achieve their mission, enhance business performance, reduce costs, and improve health for over 51 million Americans.</strong>

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Competitive Compensation and Benefits Package

Overview: For the Federal Department of Labor, Office of Workers&rsquo; Compensation Programs (OWCP), the Fraud Abuse and Detection (FAD) function is responsible for monitoring bill processing with the intent of detecting suspected cases of fraud and abuse. This function also is used to report and track these suspected cases and to provide the Government with the capabilities required to prevent fraud and abuse cases.
Responsibilities: <ul> <li>Maintain and operate a FAD function to support the ongoing, retrospective, comprehensive analysis of Government data for the detection of potential provider and claimant fraud, abuse, or improper utilization.</li> <li>Maintain and operate a FAD function that includes, but not be limited to, the following capabilities:</li> <ul> <li>Produce reports and charts as approved by the Government.</li> <li>Run fraud studies when requested by the Government.</li> <li>Provide the functionality for unrestricted aggregations of data elements.</li> <li>Provide the functionality for fraud studies.</li> </ul> <li>Perform detection and normative benchmarking, by the program, use, cost, and treatment patterns.</li> <li>Perform statistical analysis using state-of-the-art tools and industry best practices to identify cases of potential fraud and abuse.</li> <li>Perform FAD analysis using Government-approved parameters such as format, consistency with other data, etc. in FAD, including, but not limited to the following processes: <ul> <li>Perform pattern analysis of illogical or inappropriate billings across bill types and healthcare settings.</li> <li>Cross-reference multiple providers services rendered to a claimant on the same date of service.</li> <li>Provide for bill data selection, including adjustments, by date of payment and date of service and all bill types, for report generation purposes.</li> <li>Analyze treatment patterns across different bill types, such as physician office visits, ambulance trips, and equipment rentals.</li> </ul> </li> <li>Perform analyses and reviews of providers identified by fraud and abuse profiling as having aberrant billing, service, or usage patterns.</li> <li>Responsible for analyzing and proposing for government review and approval of additional fraud and abuse determination methods, algorithms, actions, activities, tools, and techniques during the period of performance of the contract.</li> </ul>
Requirements: <br /> <ul> <li>You have a Bachelor’s degree with a minimum of 5 years of Healthcare FAD experience in analyzing billings, authorizations and aberrant utilization of the services (or High School Diploma with a minimum of 8 years of this experience).</li> <li>If you have any of the below certifications, it would be “a plus”: <ul> <li>Certified Medical Coder</li> <li>Medical Auditing Certification (CPMA)</li> <li>Healthcare Administration</li> <li>RN or LPN</li> </ul> </li> </ul>