Senior SIU Analyst - FWA Detection

Summary

Senior SIU Analyst - FWA DetectionLocation: Bowie, MD Duration: 3+ Months on w2Summary: Validate whether the FWA (Fraud, Waste & Abuse) detection approach surfaces real, actionable fraud/waste/abuse signals and produce substantiated findings to support FWA product development.Responsibilities:Review claims flagged by detection logic and determine true positives versus false positives. Articulate the specific billing patterns, code combinations, or provider behaviors driving each identified issue. Carry select flagged leads through to documented, substantiated findings. Partner with Product and Data Science teams to translate investigative insights into refined detection rules. Track progress against substantiation-rate and findings-volume targets. Develop findings and recommendation memos outlining whether to scale, iterate, or discontinue detection approaches. Present findings clearly to non-investigator audiences, including Product, Compliance, and Leadership teams.4+ years of FWA investigative experience, preferably on the payer side. Direct experience with claims coding logic, including CPT/HCPCS, ICD-10, DRG, and APC methodologies. Prior experience starting investigations from a live data feed with minimal historical context. Comfortable working with partial or imperfect data sets, including sample extracts rather than fully developed production systems. One of the following certifications is required:AHFI (Accredited Health Care Fraud Investigator)CFE (Certified Fraud Examiner)CPC (Certified Professional Coder)CPMA (Certified Professional Medical Auditor)Strong SQL or equivalent self-service data querying skills.Familiarity with claims editing and rules logic, including NCCI edits.Healthcare payer SIU investigations.Fraud analytics and claims review.Cross-functional collaboration with Product and Data Science teams.Presentation of investigative findings to business and executive stakeholders.

Job Description

Senior SIU Analyst - FWA DetectionLocation: Bowie, MD Duration: 3+ Months on w2Summary: Validate whether the FWA (Fraud, Waste & Abuse) detection approach surfaces real, actionable fraud/waste/abuse signals and produce substantiated findings to support FWA product development.Responsibilities:Review claims flagged by detection logic and determine true positives versus false positives. Articulate the specific billing patterns, code combinations, or provider behaviors driving each identified issue. Carry select flagged leads through to documented, substantiated findings. Partner with Product and Data Science teams to translate investigative insights into refined detection rules. Track progress against substantiation-rate and findings-volume targets. Develop findings and recommendation memos outlining whether to scale, iterate, or discontinue detection approaches. Present findings clearly to non-investigator audiences, including Product, Compliance, and Leadership teams.4+ years of FWA investigative experience, preferably on the payer side. Direct experience with claims coding logic, including CPT/HCPCS, ICD-10, DRG, and APC methodologies. Prior experience starting investigations from a live data feed with minimal historical context. Comfortable working with partial or imperfect data sets, including sample extracts rather than fully developed production systems. One of the following certifications is required:AHFI (Accredited Health Care Fraud Investigator)CFE (Certified Fraud Examiner)CPC (Certified Professional Coder)CPMA (Certified Professional Medical Auditor)Strong SQL or equivalent self-service data querying skills.Familiarity with claims editing and rules logic, including NCCI edits.Healthcare payer SIU investigations.Fraud analytics and claims review.Cross-functional collaboration with Product and Data Science teams.Presentation of investigative findings to business and executive stakeholders.