Certified Healthcare Fraud Analyst

About the role

Codoxo is the premier provider of artificial intelligence-driven solutions and services that help healthcare companies and agencies proactively detect and reduce risks from fraud, waste, and abuse and ensure payment integrity. Codoxo helps plan partners manage costs across network management, clinical care, provider coding and billing, payment integrity, and special investigation units. Our software-as-a-service applications are built on our proven Forensic AI Engine, which uses patented AI-based technology to identify improper payment and suspicious claims behavior far faster and earlier than traditional techniques. We are venture backed by some of the top investors in the country, with strong financials, and remain one of the fastest growing healthcare AI companies in the industry.

Responsibilities

• Evaluate claims data in accordance with federal regulations, state-specific policies, or commercial guidance to identify potential fraud, waste, and abuse [FWA], claim processing errors, or improper payments.
• Maintain security and confidentiality of all protected health information encountered in performance of duties.
• Proactively identify instances of potential FWA through data analysis using company system and present findings to partners and stakeholders.
• Assist engineering, data science, and product teams with audit and FWA concepts, data mapping, and data definitions.
• Prepare and maintain statistical/financial analysis reports and graphic presentation for notification of findings to health plan partners and key stakeholders.
• Assist partner users with identifying areas of interest through navigation and work-flow optimization using company software.
• Apply knowledge of health care coding conventions, fraud schemes, general areas of vulnerability, reimbursement methodologies and relevant laws to find suspicious patterns in claims data.
• Research and apply specific knowledge of healthcare reimbursement policies as well as state and federal regulations related to potential healthcare FWA leads.
• Work cooperatively and constructively with team members, including mentoring, training, and assisting team members as required.
• Conduct professional outreach and discuss coding best practices with individual providers and billing groups - Certified Professional Coder (CPC) required.
• Prepare and submit tickets to report any concerns / issues within the company software either from a partner platform or internal platform.
• Perform additional duties and projects as assigned by management.

Qualifications

• 5+ years of experience working in a healthcare fraud investigations role.
• 5+ years of experience within the health insurance industry.
• 5+ years of experience working in a cost containment, payment integrity, fraud, audit, compliance, or analytics role.
• Certified Professional Coder (CPC) or similar coding certification required for provider outreach roles.
• 5+ years of experience within health plan, facility, government pharmacy or other similar industry role.
• Data and analytics experience.
• High School Diploma / GED or higher.
• Competency in Excel – creating/updating spreadsheets, pivot tables, and formulas.

Preferred Qualifications

• Professional Certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar.

Remote Work Requirements

To ensure reliable performance on the company-issued CODOXO laptop, employees working remotely must have a stable high-speed internet connection. Internet performance should be measured using a speed test conducted directly on the CODOXO laptop, not based solely on the internet plan purchased from the provider.

Benefits

• Health, Dental, and Vision insurance with 100% employee premium coverage (Starts Day 1)
• Unlimited PTO
• Annual Professional Development stipend
• Annual home office stipend
• 401K Match (after 90 days)