Fraud, Waste & Abuse Investigator

Key Responsibilities & Accountabilities:

• Design, implement, and maintain a comprehensive FWA program aligned with industry best practices and regulatory requirements.
• Implement FWA policies and procedures in collaboration with legal, compliance, and business units.
• Establish and oversee a robust FWA tracking and reporting system to monitor program effectiveness.
• Conduct regular FWA risk assessments to identify potential vulnerabilities and implement mitigation strategies.
• Support claims and approval team in any reported suspected fraud / abuse case.
• Conduct in-depth investigations of suspected fraud, waste, and abuse cases, utilizing advanced data analytics and investigative techniques.
• Develop and implement proactive fraud prevention strategies, including education and training programs for employees.
• Collaborate with internal and external stakeholders to share intelligence and best practices on fraud prevention.
• Develop and execute recovery plans for identified fraudulent claims.
• Conduct root cause analysis of fraud incidents to prevent recurrence.
• Implement cost-saving measures to reduce waste and optimize resource utilization.
• Prepare regular reports on FWA activities, including investigation outcomes, recoveries, and prevention initiatives.
• Provide expert advice and support on FWA matters to various departments within the organization.
• Ensure adherence to all applicable laws, regulations, and company policies related to FWA.
• Conduct regular audits and reviews of FWA processes and controls.
• Stay informed about emerging fraud trends and industry best practices.
• Contribute to the development and implementation of compliance initiatives.

Education / Certification:

• Bachelor of medicine or Bachelor in Pharmaceutical sciences.
• Previous experience in relevant fields (3 years minimum in insurance field)

Soft Skills & Behavioral Competencies:

• Excellent organizational and planning skills
• Reliable and trustworthy
• English / Computer Skills
• Ability to accurately create reports
• Detail Oriented
• Strong Analytical Skills