Fraud Investigation Analyst

Fraud Investigation Analyst page is loaded## Fraud Investigation Analyst locations:
US MA Boston time type:
Full time posted on:
Posted 30+ Days Agojob requisition :
JR109667

At Zelis, we Get Stuff Done. So, let’s get to it!

Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts – driving real, measurable results for clients.
** A Little About You
** You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are.
** Position Overview
** The Fraud Investigation Analyst, Enterprise Fraud, will contribute significantly to safeguarding Zelis against fraudulent activities by conducting comprehensive reviews of all internal and external fraud monitoring alerts, performing fraud investigations, and thoroughly documenting all findings and outcomes. In this role, you will be expected to provide timely updates on observed fraud trends and emerging patterns to assist Enterprise Fraud in developing fraud strategies and suspicious activity monitoring.
Collaboration is key in this position, as you will work closely with various areas within Zelis, including Payments Optimization, Price Optimization, Insights & Empowerment, Compliance, and People & Culture. Your ability to combine an extensive set of investigative skills with your knowledge of Zelis and our products, services, and clients, will be put to the test on a daily basis.
This role requires keen analytical skills, a passion for preventing wrong-doing, and a fervent curiosity to investigate in order to support Enterprise Fraud in prevention, detection, reporting, and monetary recovery related to financial fraud and healthcare fraud, waste, and abuse.
** What You’ll Do
*** Perform reviews and detailed link analysis utilizing various tools and reports to identify internal or external fraudulent activity, including potential Fraud, Waste, and Abuse (FWA), across all Zelis business units and functions.
* Initiate fraud investigations and handle all aspects, including detailed documentation, analysis, research, summaries and case management within the appropriate tracking systems to ensure information is accurate and timely.
* Examine public record databases, open-source records, statements, invoices, correspondence, device data and other records pertaining to the transactions, events, financial crimes, or other incidents under investigation.
* Develop working relationships and communicate with federal, state, and local officials, and other organizations and individuals related to investigations for the purpose of gathering facts, obtaining statements, learning sequences of events, obtaining explanations, and otherwise advancing investigative objectives.
* Through regular participation in industry groups and associations, maintain up-to-date knowledge and awareness of best practices in fraud detection and prevention, investigative fraud techniques, fraud industry trends, and significant fraud events.
* Identify and recommend policy, procedure and system changes to enhance investigative outcomes and performance.
* Contribute to the creation and updating of Enterprise Fraud documentation (e.g. Standard Operating Procedures) and data repositories (e.g. Known Fraud Data Negative List.)
* On limited occasions, conduct investigations after hours or on weekends for escalated or high-priority Fraud events.
** What You’ll Bring to Zelis
*** Bachelor's degree is required, preferably in Criminal Justice, Finance, Accounting, or Business Administration.
* 4+ years of experience related to fraud prevention, financial services, risk management, or compliance, preferably in the healthcare industry.
* Professional industry certification as a Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), Health Care Anti-Fraud Associate (HCAFA), Certified Financial Crimes Investigator (CFCI), or Certified Financial Crime Specialist (CFCS), preferred.
* Proficient knowledge of Microsoft Excel, Word, PowerPoint, and case management or case review applications.
* Strong logical, analytical, and critical thinking skills, paired with a willingness to solve problems using creativity and innovation.
* Ability to effectively determine fraud risk while remaining objective and separating facts from opinions.
* Demonstrate high ethical standards that drive initiative, excellent…