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Clinical Fraud, Waste and Abuse Subject Matter Expert

at General Dynamics Information Technology in Bangor, Maine, United States

Job Description

Type of Requisition: Regular

Clearance Level Must Be Able to Obtain: None

Public Trust/Other Required: None

Job Family: Data Science

At GDIT, people are our differentiator. Our work depends on a Fraud, Waste and Abuse Subject Matter Expert (FWA SME) joining our team to support Centers for Medicare and Medicaid Services anti-fraud activities. As a FWA SME supporting the Healthcare Fraud Prevention Partnership, you will be trusted to guide fraud detection strategies and communicate outcomes to a large partnership of public and private healthcare payers. You will be a part of a 12-person team supporting the Trusted Third Party fraud, waste and abuse data analytics.

We are GDIT. The people supporting and securing some of the most complex government, defense, and intelligence projects across the country. We ensure today is safe and tomorrow is smarter. Our work has meaning and impact on the world around us, but also on us, and that’s important.

GDIT is your place. You make it your own by embracing autonomy, seizing opportunity, and being trusted to deliver your best every day.

We think. We act. We deliver. There is no challenge we can’t turn into opportunity.

In this role, a typical day will include:

+ This position is within a multi-disciplinary team of Data Scientists, Business Intelligence Analysts and other FWA SMEs. Our team is 100% remote and distributed throughout the country.

+ This position will be responsible for supporting FWA study development and execution activities in multi-payer type environments, advising data science staff on clinical, policy and billing aspects of FWA study design.

+ This team member will have an in-depth understanding of and ability to educate various audiences about how claims data are reported, processed, and ultimately inform study results.

+ This position involves policy, program and industry research, and will synthesize research findings into cogent analytic rationale that can be articulated to end users.

+ This position involves the preparation and editing of written documents, spreadsheets, presentations and other artifacts.

+ This team member will be called upon to identify actionable findings within the analytic output across the several dozen HFPP Partners; the position likewise involves packaging and communicating those value propositions to the various enforcement arms within the healthcare fraud partnership, including: private payers SIUs, government administrative agencies such as CMS and Medicaid programs, and Law Enforcement.

REQUIRED QUALIFICATIONS

+ Registered Nurse (RN), Bachelor of Science in Nursing (BSN), Licensed Practical Nurse (LPN) or similar caliber clinical training and experience.

+ Certified Professional Coder (CPC) through the American Academy of Professional Coders (AAPC) or Certified Coding Specialist (CCS) through the American Health Information Management Association (AHIMA)

+ 15+ years of relevant experience in healthcare.

+ 10+ years of relevant experience in healthcare fraud investigations, with demonstrable experience across the spectrum of fraud detection within two or more of the following program types: Medicare, Medicaid, Private Insurance

+ 10+ years of experience utilizing medical claims coding systems (e.g., ICD-10, CPT, HCPCS, NDC)

+ Strong knowledge of health care benefit structure and claim processing systems

+ Experience researching and interpreting payer medical (coverage) policies (e.g., LCDs, NCDs, private carrier medical policies) and common industry claim edits (e.g., NCCI)

DESIRED QUALIFICATIONS

+ Deep experience in CMS/CPI fraud, waste and abuse contracts.

+ Knowledge of data analysis techniques for fraud, waste and abuse detection, and documentation of those models.

+ Ability to communicate technical and non-technical language to technical and non-technical audiences

+ Ability to prioritize multiple tasks to meet established deadlines and satisfy internal and external customer demands

+ Proficient in Microsoft products, Tableau

+ Ability to compile and deliver public presentations when necessary

WHAT GDIT CAN OFFER YOU

+ The GDIT HFPP Trusted Third Party is the only data warehouse of its type anywhere, bringing in many billions of healthcare claims from dozens of healthcare payers, including federal, state and local plans both public and private. We use this data warehouse solely for fraud, waste and abuse analytics.

+ The TTP is responsible for identifying overpayments, fraud leads, and meaningful insights about abusive billing behaviors through a cross-payer lens. Government and private healthcare organizations collaborated to form the HFPP as a public-private partnership to combat fraud, waste, and abuse.

+ Competitive pay and benefits, flexible work schedule, collaborative inter-disciplinary environment where the best idea wins.

GDIT CAREERS

Opportunity Owned

Discover more at www.gdit.com/careers

General Dynamics Information Technology is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status, or any other protected class.

We are GDIT. The people supporting some of the most complex government, defense, and intelligence projects across the country. We deliver. Bringing the expertise needed to understand and advance critical missions. We transform. Shifting the ways clients invest in, integrate, and innovate technology solutions. We ensure today is safe and tomorrow is smarter. We are there. On the ground, beside our clients, in the lab, and everywhere in between. Offering the technology transformations, strategy, and mission services needed to get the job done.

GDIT is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status, or any other protected class.

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Job Posting: JC187678385

Posted On: Jul 13, 2021

Updated On: Aug 12, 2021