FWA Auditor - Medicare/Medicaid Claims Investigator

CPC/CPMA required Nov 16th to Feb 8th might extend Fraud Waste Abuse exp Commercial Medicare/ Medicaid on site Bowie MD 3 days a week SQL exp Exp with Health plans Person needs to review current work Summary: Validate whether the FWA detection approach surfaces real, actionable fraud/waste/abuse signal, and produce substantiated findings to support FWA product development. Responsibilities Review claims flagged by detection logic and determine true positive vs. false positive Articulate the specific billing pattern, code combination, or provider behavior driving each call Carry select flagged leads through to a documented, substantiated finding Partner with product and data science teams to translate investigative judgment into refined detection rules Track progress against substantiation-rate and findings-volume targets (set once POC window and initial data are confirmed) Write a findings/recommendation memo — scale, iterate, or kill — for internal stakeholders Present findings clearly to non-investigator audiences (product, compliance, leadership) Skills: Qualifications: 4+ years FWA investigative experience, payer-side preferred Direct exposure to claims coding logic (CPT/HCPCS, ICD-10, DRG/APC) Must have prior experience starting cold on a live data feed Comfortable working from partial/imperfect data — sample extracts, not a finished production system Certification required: AHFI, CFE, or CPC/CPMA SQL or equivalent self-serve query ability Familiarity with edit/rules logic (e.g., NCCI edits) Education: Bachelor's degree, or 7+ years relevant experience in lieu CPC/CPMA required Nov 16th to Feb 8th might extend Fraud Waste Abuse exp Commercial Medicare/ Medicaid on site Bowie MD 3 days a week SQL exp Exp with Health plans Person needs to review current work Summary: Validate whether the FWA detection approach surfaces real, actionable fraud/waste/abuse signal, and produce substantiated findings to support FWA product development. Responsibilities Review claims flagged by detection logic and determine true positive vs. false positive Articulate the specific billing pattern, code combination, or provider behavior driving each call Carry select flagged leads through to a documented, substantiated finding Partner with product and data science teams to translate investigative judgment into refined detection rules Track progress against substantiation-rate and findings-volume targets (set once POC window and initial data are confirmed) Write a findings/recommendation memo — scale, iterate, or kill — for internal stakeholders Present findings clearly to non-investigator audiences (product, compliance, leadership) Skills: Qualifications: 4+ years FWA investigative experience, payer-side preferred Direct exposure to claims coding logic (CPT/HCPCS, ICD-10, DRG/APC) Must have prior experience starting cold on a live data feed Comfortable working from partial/imperfect data — sample extracts, not a finished production system Certification required: AHFI, CFE, or CPC/CPMA SQL or equivalent self-serve query ability Familiarity with edit/rules logic (e.g., NCCI edits) Education: Bachelor's degree, or 7+ years relevant experience in lieu Estimated Min Rate : $45.50 Estimated Max Rate : $65.00 What’s In It for You? We welcome you to be a part of the largest and legendary global staffing companies to meet your career aspirations. Yoh’s network of client companies has been employing professionals like you for over 65 years in the U.S., UK and Canada. Join Yoh’s extensive talent community that will provide you with access to Yoh’s vast network of opportunities and gain access to this exclusive opportunity available to you. Benefit eligibility is in accordance with applicable laws and client requirements. Benefits include: Medical, Prescription, Dental & Vision Benefits (for employees working 20+ hours per week) Health Savings Account (HSA) (for employees working 20+ hours per week) Life & Disability Insurance (for employees working 20+ hours per week) MetLife Voluntary Benefits Employee Assistance Program (EAP) 401K Retirement Savings Plan Direct Deposit & weekly epayroll Referral Bonus Programs Certification and training opportunities Note: Any pay ranges displayed are estimations. 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