Health Insurance Specialist

Reviews financial payment data and provider enrollment records to spot potential fraud, waste, and abuse (FWA). Uses established guidelines and analytical tools to evaluate issues, conduct studies, and identify program vulnerabilities. Assists with developing, reviewing, and updating program integrity policies and regulations. Identifies policy problems, recommends solutions, and contributes to decisions that may result in new or improved rules, criteria, or agency policies particularly around administrative sanctions and integrity initiatives. Coordinates with Internal and external agencies on fraud, waste, and abuse (FWA) matters by compiling case documentation and factual summaries as well as engaging with senior officials across the healthcare industry, nonprofits, and contractors. Prepares and delivers briefing materials, summary reports, and analytical findings for senior officials and provides technical advice to internal and external stakeholders on provider enrollment, program