**Department Name:** Compliance **Work Shift:** Day **Job Category:** General Operations **Estimated Pay Range:** $29.11 - $48.51 / hour, based on location, education, & experience. In accordance with State Pay Transparency Rules. Great careers are built at Banner Health. We’re looking for the best and brightest to join our team that earned Great Place to Work® Certification™. Apply today to build your career. Banner Plans & Networks (BPN) is an integrated network for Medicare, Medicaid, and private health plans. Known nationally as an innovative leader, BPN insurance plans and physicians work collaboratively to keep members in optimal health while reducing costs. Supporting our members and vast network of providers is a team of professionals known for innovation, collaboration, and teamwork. If you would like to contribute to this leading-edge work, we invite you to bring your experience and skills to BPN. As a Fraud, Waste, and Abuse Specialist, you will be responsible for identifying and researching potential instances of fraud, waste, or abuse within claims and documentation. Your duties will include: conducting research and reviewing documentation from referrals, analyzing claims reports and invoices submitted to the claims department, contacting members to verify services received, reviewing provider documentation for accuracy and compliance, attending meetings with the H2O (Housing and Health Opportunities) Housing Administrator, preparing comprehensive reports for providers and H2O program stakeholders, providing training and guidance to providers, analyzing patterns in claims and documentation to identify potential compliance issues, performing data mining and analysis, drafting and sending official correspondence, generating claims reports and supplying data for committee review, and performing other duties as assigned. This role offers a dynamic work environment with varied responsibilities from day to day. Required Qualifications: **This role requires candidates to hold either the Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) credentials, issued by either AAPC or AHIMA.** Preferred Qualifications: 2+ years of experience in claims processing, billing, or healthcare compliance. Experience with audit processes Knowledge of Medicare/Medicaid regulations Strong analytical and investigative skills Excellent communication skills for member and provider interactions. **This is a fully remote position; however, candidates must reside in the State of Arizona to meet compliance requirements** . Work hours are Monday through Friday, consisting of eight-hour shifts with some flexibility in starting and ending times. If you're looking for a rewarding opportunity with flexibility and purpose, we encourage you to apply today! Banner Health Network (BHN) is an accountable care organization that joins Arizona's largest health care provider, Banner Health, and an extensive network of primary care and specialty physicians to provide the most comprehensive healthcare solutions for Maricopa County and parts of Pinal County. Through BHN, known nationally as an innovative leader in new health care models, insurance plans and physicians are coming together to work collaboratively to keep members in optimal health, while reducing costs. POSITION SUMMARY This position provides an organized approach to the prevention, detection, and reporting of fraud, waste, and abuse. This position is primarily responsible for the analysis, auditing and monitoring activities related to the detection of fraud, waste, and abuse; and identifying potential problems. Understands key business objectives and health plan operations and assists with the follow-up and implementation of process and procedure improvements related to audit findings. Report findings to Operations Management to utilize for process improvement. CORE FUNCTIONS 1. Performs data analysis of provider claims history to substantiate fraud and abuse allegations stemming from tips, subject matter experts, professional associates and other source of fraud, waste and abuse information. 2. Conduct independent & original research through both internal & external sources and databases. 3. Conduct initial assessment of incoming referrals, and complete related documentation. 4. Interact / coordinates activities with all levels of leadership on course of investigation or analytical plans. 5. Prepare accurate monthly, and ad-hoc management reports to detect and identify fraud trends, analysis of those trends and risk mitigation recommendations. Reports activities to management on a regular basis. 6. Designs and generates reports with trend analysis. Investigates and identifies unusual trends and causes. Generates and creates benchmarking results which may also include dashboard reporting. 7. Maintains working knowledge of AHCCCS and Medicare rules and regulations (must include knowledge of CPT, ICD-9, ICD-10 coding, HCPCS and DRGs) 8. Assist managerial staff in developing and maintaining specific work procedures, policies and procedures and process improvement projects. 9. This position primarily focuses on supporting investigations to aid in the prevention of waste, fraud and abuse of the health plan. This position has frequent interaction with internal and external parties including but is not limited to, employees, providers, members, suspects, witnesses, law enforcement and legal counsel. MINIMUM QUALIFICATIONS Requires one to two years experience with health care claims required, two years auditing experience in an insurance and/or healthcare environment. Healthcare experience including AHCCCS / Medicare experience. Requires experience with process improvement projects and ability to plan/direct projects. Requires ability to pay attention to details and solid analytical, problem solving and organizational skills. Ability to analyze and trend data. Proficient in Microsoft Office software (Word, Excel, Access, PowerPoint). PREFERRED QUALIFICATIONS Experience with the IDX Claims System highly preferred. Experience with claims/billing with providers/health plans highly preferred. Certified Fraud Examiner (CFE) certification and Bachelor degree preferred. Additional related education and/or experience preferred. **EEO Statement:** EEO/Disabled/Veterans (https://www.bannerhealth.com/careers/eeo) Our organization supports a drug-free work environment. **Privacy Policy:** Privacy Policy (https://www.bannerhealth.com/about/legal-notices/privacy) EOE/Female/Minority/Disability/Veterans Banner Health supports a drug-free work environment. Banner Health complies with applicable federal and state laws and does not discriminate based on race, color, national origin, religion, sex, sexual orientation, gender identity or expression, age, or disability