Capital Blue Cross

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SIU Healthcare Fraud Data Analyst

Job Locations US-PA-Harrisburg
Workplace
Remote
Employment Type
Full Time
ID
2025-3817
Min
USD $60,630.00/Annually
Max
USD $117,690.00/Annually

Position Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.  

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”    

The SIU Data Analyst primary responsibility is to analyze healthcare data to identify suspicious activities, potential fraud schemes, and trends that may indicate fraudulent behavior. The role involves analyzing large set of data to identify anomalies, irregular patterns and trends, utilize advanced analytical techniques to detect, assess and report potential fraud cases, perform detailed data mining to detect fraud patterns or trends in medical claims, billing practices, and provider activities, leverage specialized fraud detection tools, software and databases to streamline fraud detection and reporting processes and monitor and report emerging fraud trends and patterns in the health care sector. 
The SIU Fraud Analyst is responsible for working with SIU investigators to detect, investigate, and prevent fraudulent activities within the company. This role involves the initial review and triage of potentially fraudulent activities, analyzing data, prioritizing cases, preparing them for further investigation, and producing detailed reports on findings and trends. The ideal candidate will possess strong analytical skills, attention to detail, and a background in fraud detection.

Responsibilities and Qualifications

  • Collects and analyzes data for proactively identifying suspicious trends and patterns of potential fraud, waste or abuse activities.  Produce detailed analytical reports on fraud trends, risk factors, and potential vulnerabilities to inform prevention strategies.
  •  Utilize data analysis techniques to detect aberrancies in medical and pharmacy claims data, and proactively seeks out and develops leads/investigations received from a variety of sources (e.g., Anti-Fraud software, CMS, OIG, DHS, and fraud alerts)
  • Collaborates with investigative team to present data including leads, complaints, and/or trends to determine if further investigational activities are warranted.
  • Evaluates and monitors the department's metrics and proactively documents trends with detailed descriptions of possible business impacts.  Develops, generates, and revises routine and ad-hoc detail and summary level reports, including written interpretation of analytic results and report automation.
  • Develop documentation to substantiate findings, including formal reports, graphs, audit logs, and other supporting documentation.
  • Perform root cause analysis to inform future algorithmic identification of similar claims or cases and associated savings (i.e., help move identified case types from "pay-and-chase" to preventive edits and pre-payment activity)
  • Responds to law enforcement and SIU industry requests for information (RFI) to collaborate with national case investigations. 

Experience:

  • Experience with healthcare data systems (i.e. FACETS)
  • Familiarity with fraud detection software, SQL, and Crystal Reports
  • Minimum of 2-4 years’ experience in health care fraud detection, data analysis or a related field

Skills:

  • Strong analytical, critical thinking and problem-solving skills
  • Ability to work independently with demonstrated ability to take initiative in problem resolution.
  • Ability to interpret complex healthcare data to identify trends and patterns of fraud, waste or abuse type behavior

Knowledge:

  • Knowledge of applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity
  • Experience working in health insurance across several products specifically with claims processing, billing, reimbursement, or provider contracting.
  • Proficiency in SQL, Excel, data visualization tools (e.g., Tableau, Power BI, Crystal Reporting), and statistical analysis software (e.g., RAT STATS).

Education/Certifications

  • Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), preferred
  • Certified Professional Coder (CPC), preferred
  • 4 years' health insurance claims investigation experience or professional investigation experience with law enforcement agencies OR bachelor’s degree in data science, computer science, healthcare administration, criminal justice or a related field.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live. 

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Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. We are an equal opportunity employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.