Sr. FWA Analyst

Bluespine is an innovative new startup in the health-IT domain. By employing cutting-edge technologies, Bluespine is developing an engine that detects errors in medical billing, which causes billions of dollars in losses across the entire industry. Bluespine can offer personalized precision by tailoring assessments to each unique medical claim, considering the relevant provider, payer, and plan, and ensuring unparalleled accuracy.

We are looking for a Sr. FWA Analyst experienced in discovering medical billing errors and fraudulent billing patterns of medical claims for commercial payers.

Responsibilities

• Proactively identify potential instances of fraud, waste, and abuse through data analysis using company systems and tools
• Support engineering and data science teams with audit and FWA concepts, data mapping, and defining data requirements
• Determine the likelihood of cases being true error/fraud, based on real-life experience.
• Validate and help to tune anomaly detection algorithms.

Requirements

• Hands-on experience exploring and investigating potential medical billing errors/fraud using analytic and SQL/graph-based tools.
• Extensive knowledge of medical terminology, medical records, health information management, medical coding, DRG methodologies, CPT/HCPCS coding guidelines, physician specialty guidelines, reimbursement programs, claims adjudication processes, member contract benefits, regulatory agency policies (CMS/HCFA, DOI, state regulations), and provider billing systems and practices.
• Strong analytical skills and ability to approach tasks in a scientific manner.
• Background in SIU or Payment Integrity.
• Independent, Organized, and with excellent communication skills.

Advantages

• Medical/clinical background.
• Experience with Pharma claims.
• Billing/coding experience.