Fraud & Abuse Auditor

GENERAL DESCRIPTION: Conducts Fraud, Waste, and Abuse (FWA) audits, monitoring, and data analysis of medical and related claims to detect aberrant billing patterns, improper payments, and potential non-compliance with federal and state healthcare program requirements. Supports the Company’s Program Integrity framework by identifying, documenting, and reporting FWA risks, audit findings, and corrective action recommendations. Assists in investigations involving potential fraud, abuse, waste, marketing violations, financial exploitation, and other compliance or regulatory matters, in coordination with internal stakeholders and external agencies, as required. ESSENTIAL FUNCTIONS: •Collaborates with management to design risk‑based audit and monitoring initiatives aligned with regulatory and Program Integrity requirements. •Applies advanced data analytics and monitoring techniques to identify patterns, trends, outliers, and potential FWA schemes. •Develops and analyzes complex claims, provider, and member data reports to detect FWA, improper payments, and billing anomalies. •Reviews multiple data sources, provider contracts, and regulatory requirements to validate findings and support Program Integrity activities. •Identifies and documents root causes of FWA findings and develops corrective action plans to mitigate risk. •Calculates potential overpayments, recoveries, and cost‑avoidance opportunities using analytical methodologies. •Supports FWA investigations, delegated entity oversight, regulatory reporting, and the enhancement of monitoring tools. •Communicates audit and monitoring results, identified risks, and escalation issues to management and operational stakeholders. •Prepares written and verbal communications to providers regarding FWA findings, overpayments, and remediation actions. •Maintains complete and defensible documentation of analyses, methodologies, findings, corrective actions, and follow‑up activities. ADDITIONAL FUNCTIONS: • Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. • May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: Bachelor’s degree. At least three (3) years of experience in medical claims evaluation within a health insurance environment, including Medicare physician payment rules, data reporting, and database management, and support of FWA, Program/Payment Integrity, SIU, or Compliance functions, with exposure to claims analysis, billing practices, provider behavior, and contracting terms. “Proven experience may be replaced by previously established requirements.” Certifications / Licenses : Not required. Other: Proficient in Excel. Strong knowledge of medical claims adjudication, reimbursement methodologies, and payment integrity concepts, including improper payments and overpayment recovery. Knowledge of FWA regulations and guidance, including the Center of Medicare and Medicaid Services (CMS) Program Integrity requirements, federal and state fraud statutes, False Claims Act considerations, and recoupment and recovery standards. Languages: Spanish – Advanced (comprehensive, writing and verbal) English – Advanced (comprehensive, writing and verbal)