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).
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)
Skills: Bachelor's degree, or 7+ years relevant experience in lieu.
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At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws.This position's pay range is $70.00/hr - $72.00/hr.
