Claims Investigation Analyst

Claims Investigation Analyst

At WelbeHealth, we serve our communities’ most vulnerable seniors through shared intention, pioneering spirit, and the courage to love. These core values and our participant-focus lead the way no matter what.

The Claims Investigation Analyst plays a crucial and multifaceted role within the organization, serving as a key component in the comprehensive effort to meticulously examine and identify potentially fraudulent activities related to claims billing, processing, and payment. This role involves conducting in-depth investigations that require a keen eye for detail, as well as analyzing complex and often intricate data patterns to uncover inconsistencies or anomalies that may indicate fraudulent behavior. The Claims Investigation Analyst actively works to verify the legitimacy of claims by cross-referencing data, validating supporting information, and utilizing specialized tools and techniques.

This role is different because the Claims Investigation Analyst at WelbeHealth:

· Investigates claims in a setting that serves frail seniors, meaning your work has a real, immediate impact on care delivery, access, and continuity, not just financial reports like in traditional claims roles

· Focuses on both detecting issues and strengthening processes, making you a proactive partner in improving care delivery rather than a reactive auditor

We care about our team members. That’s why we offer:

· Medical insurance coverage (Medical, Dental, Vision)

· Work/life balance - We mean it! 17 days of personal time off (PTO), 12 holidays observed annually, and 6 sick days

· 401K savings + match

· Comprehensive compensation package including base pay and bonus

· And additional benefits!

On the day-to-day, you will:

· Analyze incidents of suspected fraud, waste, and abuse in accordance with regulatory requirements and organization policies

· Conduct investigations to proactively prevent, detect, and correct suspected and identified issues of fraud, waste, and abuse by utilizing a variety of sources including data analytics to detect unusual billing

· Thoroughly review all claim documentation, including supporting records and correspondence, to ensure the integrity of the claims process and maintain strict compliance with regulatory standards and organizational policies

· Collaborate with internal stakeholders on findings, reporting, and remediation

· Educate external providers on proper billing practices

Job requirements include:

· High school diploma required, bachelor’s degree in relevant field preferred

· Minimum of four (4) years of relevant professional experience in a healthcare environment with an emphasis on fraud, waste, and abuse reviews/investigations, or claims pertaining to fraud, waste, and abuse

· Strong knowledge of PACE, managed care, and Medi-Cal and Medicare programs

· Knowledge of federal and state guidelines as well as ICD, CPT, HCPCS, coding

We are seeking Claims Investigation Analysts that ideally have experience working in a PACE/healthcare environment. If you’re ready to join a team that values both its participants and team members, we’d love to hear from you!

COVID-19 Vaccination Policy

At WelbeHealth, our mission is to unlock the full potential of our vulnerable seniors. In this spirit, please note that we have a vaccination policy for all our employees and proof of vaccination, or a vaccine declination form will be required prior to employment. WelbeHealth maintains required infection control and PPE standards and has requirements relevant to all team members regarding vaccinations.

Our Commitment to Diversity, Equity and Inclusion

At WelbeHealth, we embrace and cherish the diversity of our team members, and we're committed to building a culture of inclusion and belonging. We're proud to be an equal opportunity employer. People seeking employment at WelbeHealth are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), pregnancy or other status protected by applicable law.

Beware of Scams

Please ensure your application is being submitted through a WelbeHealth sponsored site only. Our emails will come from @welbehealth.com email addresses. You will never be asked to purchase your own employment equipment. You can report suspected scam activity to [email protected]