Fraud, Waste and Abuse (FWA) Claims Specialist
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What you'll do
- Conducting thorough investigations of suspected FWA cases, analyzing data and identifying patterns.
- Ensuring adherence to relevant FWA laws, regulations and policies.
- Interpreting and analyzing data to identify trends, opportunities and potential FWA schemes.
- Preparing reports and documentation as needed on FWA investigations, findings, remediations and/or recommendations.
- Developing and delivering training programs on FWA prevention and identification
- Working with internal and external stakeholders, including auditors, investigators and legal professionals.
- Ensuring the accuracy and integrity of data and processes related to FWA.
- Review of all foreign claims for legitimacy and currency conversion as needed
- Follow all HIPAA guidelines for the release of information
- Request additional information as needed and coordinate escalations with medical review vendor.
- Interpret Summary Plan Document language
- Obtain notifications/information from resources to do focused reviews; work with client on referrals/attend client meetings
What they're looking for
- High School/GED required.
- 5-8 years’ experience in FWA analyses and/or Medical and coding/FWA Reviews
- Claims processing experience
- Medical claims and coding knowledge
- Benefit, contract, and pricing interpretation knowledge
- US Citizen or US Green Card only
Nice to have
- College degree, Certified billing/coding and/or nursing degree preferred.
- Claims processing knowledge relative to procedural and diagnosis coding – CPT, HCPCS, Rev codes, DRG, ICD 10 codes, and/or medical terminology is a plus
Summarised by NextRaise from the employer’s description, which follows in full below.
Full description from employer
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Wipro Limited (NYSE: WIT, BSE: 507685, NSE: WIPRO) is a leading technology services and consulting company focused on building innovative solutions that address clients’ most complex digital transformation needs. Leveraging our holistic portfolio of capabilities in consulting, design, engineering, and operations, we help clients realize their boldest ambitions and build future-ready, sustainable businesses. With over 230,000 employees and business partners across 65 countries, we deliver on the promise of helping our customers, colleagues, and communities thrive in an ever-changing world. For additional information, visit us at www.wipro.com.
Job Description
Fraud, Waste and Abuse (FWA) Claims Specialist
Job-Type: Full-time direct hire position.
Location: Remote, US only
Work authorization: US Citizen or US Green Card only
Pay: $25-30 per hour
Hours: Monday-Friday 8am-5pm EST
Position Summary
A Fraud, Waste and Abuse (FWA) Specialist investigates and analyzes potential FWA cases and reviews ensuring compliance with regulations and policies and recommending corrective actions. They may be involved in identifying, validating and recovering overpayments as well as researching and developing new FWA job aides.
Additional Job Duties
- Investigation and Analysis: Conducting thorough investigations of suspected FWA cases, analyzing data and identifying patterns.
- Compliance: Ensuring adherence to relevant FWA laws, regulations and policies.
- Data Analysis: Interpreting and analyzing data to identify trends, opportunities and potential FWA schemes.
- Reporting: Preparing reports and documentation as needed on FWA investigations, findings, remediations and/or recommendations.
- Training and Education: Developing and delivering training programs on FWA prevention and identification
- Collaboration: Working with internal and external stakeholders, including auditors, investigators and legal professionals.
- Quality Assurance: Ensuring the accuracy and integrity of data and processes related to FWA.
- Review of all foreign claims for legitimacy and currency conversion as needed
- Follow all HIPAA guidelines for the release of information
- Request additional information as needed and coordinate escalations with medical review vendor.
- Interpret Summary Plan Document language
- Obtain notifications/information from resources to do focused reviews; work with client on referrals/attend client meetings
- Work with the Appeals Team to assist with medical review activities
Requirements
- High School/GED required. College degree, Certified billing/coding and/or nursing degree preferred.
- 5-8 years’ experience in FWA analyses and/or Medical and coding/FWA Reviews
- Claims processing experience
- Medical claims and coding knowledge
- Benefit, contract, and pricing interpretation knowledge
Preferences
- Claims processing knowledge relative to procedural and diagnosis coding – CPT, HCPCS, Rev codes, DRG, ICD 10 codes, and/or medical terminology is a plus
Licensing/Certifications
- Certified billing/coding and/or nursing degree preferred.
Mandatory Skills: Claims
The expected compensation for this role ranges from $25-30 per hour.
Final compensation will depend on various factors, including your geographical location, minimum wage obligations, skills, and relevant experience. Based on the position, the role is also eligible for Wipro's standard benefits including a full range of medical and dental benefits options, disability insurance, paid time off (inclusive of sick leave), other paid and unpaid leave options.
Applicants are advised that employment in some roles may be conditioned on successful completion of a post-offer drug screening, subject to applicable state law.
Wipro provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. Applications from veterans and people with disabilities are explicitly welcome.
Reinvent your world. We are building a modern Wipro. We are an end-to-end digital transformation partner with the boldest ambitions. To realize them, we need people inspired by reinvention. Of yourself, your career, and your skills. We want to see the constant evolution of our business and our industry. It has always been in our DNA - as the world around us changes, so do we. Join a business powered by purpose and a place that empowers you to design your own reinvention.
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