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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 Pro