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The School District of Philadelphia
Philadelphia, PA, United States
NOTE - In order to be considered for this position, you MUST submit a cover letter that is specific to this role. This is a full-time, Non-Represented role. The salary grade for this posting is 4024. The salary range is $53,834 to $72,496 . Please note that the final salary will be determined by our Classification and Compensation team after revie
Job Source: The School District of PhiladelphiaBlue Cross and Blue Shield Association
Philadelphia, PA, United States
Our organization is looking for dynamic individuals who love to learn, thrive on innovation, and are open to exploring new ways to achieve our goals. If this describes you, we want to speak with you. You can help us achieve our vision to lead nationally in innovating equitable whole-person health. The Auditor Payment Integrity audits claims submitt
Job Source: Blue Cross and Blue Shield AssociationThe School District Of Philadelphia
Philadelphia, PA, United States
Note: All interested parties must attach a cover letter. This is a full-time, Non-Represented role. The salary grade for this posting is 4024. The salary range is $55,449 to $74,671 . Please note that the final salary will be determined by our Classification and Compensation team after reviewing the candidate's experience and considering our inter
Job Source: The School District Of PhiladelphiaCapgemini
Malvern
Fraud Investigator **Job Title:** Fraud Investigator **Location:** Malvern, PA **Responsibilities:** + Leads and implements fraud prevention, detection, investigation and response activities for fraud and enterprise security programs and activities, including assessments, risk prioritizations, mitigation planning, and execution consistent with law,
Job Source: CapgeminiAptino, Inc.
Philadelphia, PA, United States
Must Haves: Daily review of assigned tasks. Lead and execute fraud prevention, detection, investigation, and response activities. Conduct assessments, risk prioritization, mitigation planning, and execution. Identify, report, and assist with large-scale fraud events. Manage and lead fraud investigation processes. Develop and implement systems for f
Job Source: Aptino, Inc.Independence Blue Cross
Philadelphia, PA, United States
Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve. JOB DESCRIPTION for Financial Investigator III Responsible for the detection, analysis an
Job Source: Independence Blue CrossBlue Cross and Blue Shield Association
Philadelphia, PA, United States
Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve. JOB DESCRIPTION for Financial Investigator II or III (Level of the role is contingent on
Job Source: Blue Cross and Blue Shield AssociationThe Behavioral Wellness Center at Girard
Philadelphia, PA, United States
*$2000 Sign-On Bonus* The Behavioral Wellness Center at Girard is a Philadelphia Drug & Alcohol Treatment Cente r offering both inpatient and outpatient Psychiatric and Substance Abuse counseling and t reatments. The Behavioral Wellness Center at Girard has always been at the forefront of innovation in providing treatment services for indiv
Job Source: The Behavioral Wellness Center at GirardKing of Prussia, PA, United States
Job Description Job Description We are hiring for a Fraud, Waste, and Abuse Specialist to join the team! Multilingual abilities are strongly preferred due to the nature of this role, but not required. 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 Geo-blue's efforts to reduce unnecessary medical spend 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.
Responsibilities:
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, Customer Service, 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 full scope of identified fraudulent activity.
Track activity and produce reports to measure impact and document actions.
Other duties as assigned.
Requirements:
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 Geo-blue'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 deal with ambiguity and drive for resolution.
Willingness and ability to learn and apply new skills.
Multi-lingual strongly preferred.
Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).
Working Conditions:
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.
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.
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Email Alert for Fraud Waste & Abuse Specialist jobs in King of Prussia, PA, United States
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