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Role Description

The Sr. Fraud Advisor within eFWA Services is responsible for delivering expert fraud prevention and compliance support to clients, ensuring adherence to regulatory standards, and driving operational excellence. This role involves managing audits, client consultations, reporting, and compliance activities while serving as a trusted advisor on fraud-related matters. The Sr. Fraud Advisor will collaborate with internal teams and external stakeholders to mitigate fraud risks, maintain compliance, and enhance client satisfaction.

Qualifications

• Education: Bachelor’s degree in Healthcare Administration, Business, Criminal Justice, or related field (Master’s preferred).
• Experience: Minimum 5+ years in healthcare fraud prevention, compliance, or auditing; experience with CMS audits, Medicare/Medicaid programs, and regulatory reporting.
• Certifications: Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or similar preferred.
• Technical Skills: Proficiency in Microsoft Excel, reporting tools, and audit documentation systems; familiarity with Health Care Fraud Shield and related platforms.

Requirements

• Client Consultation: Serve as the primary point of contact for client inquiries and consultations; conduct quarterly client consultation sessions; provide strategic guidance on fraud prevention and compliance requirements.
• Audits: Perform client audits to ensure contractual and regulatory compliance; conduct internal audits; support CMS audits and maintain tracer documentation for audit readiness.
• Client Reporting: Prepare and deliver quarterly reports to clients; complete Excellus reports by the 10th of each month; ensure timely and accurate reporting aligned with client expectations.
• Field Alerts: Issue monthly commercial alerts by the 15th; coordinate SAM COM notifications; prepare quarterly outlier reports for Medicare Part D within 45 days of CMS data availability announcements.
• Compliance & Policy Meetings: Participate in compliance and policy meetings; provide fraud-related insights and recommendations.
• Industry Engagement: Represent the organization on Health Care Fraud Shield monthly calls to stay informed on emerging fraud trends and tools.
• Operational Performance: Maintain and update the Operations Workbook with performance data; monitor KPIs and identify areas for improvement.
• Requests for Information (RFI): Manage Medicare-specific RFIs; ensure timely and accurate responses.
• Requests for Proposal (RFP): Support RFP development and submission processes for fraud-related services.
• Ad-Hoc Client Requests: Respond to high-volume ad-hoc client questions and project requests; provide timely, accurate, and actionable solutions.

Benefits

• If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

Company Description

Our culture is built on collaboration, inclusivity, and continuous improvement. We believe that success comes from working together across boundaries and fostering an environment where every voice matters. Employees are encouraged to share ideas, learn from challenges, and embrace innovation. We prioritize belonging and engagement, knowing that when people feel connected, they thrive. Our ethos emphasizes honesty, trust, and transparency, ensuring that integrity guides every decision. We celebrate diversity, encourage growth, and create opportunities for employees to do extraordinary things while enjoying their work.