SIU Fraud Claim Analyst - (Dayton, OH)

Responsible for review of FICO IFM incoming scored claims, electronic inquiries, medical records work queues as well as claim reviews for provider pre-payment function Responsible for making claim payments decisions on a wide variety of claims within department standards Responsible for researching, analyzing, and making payment decisions on claims with high FICO scores indicating possible fraud, waste and abuse Acts as a technical resource to new associates by reviewing claims, training staff, responding to claim questions and so on Responsible for identifying and implementing process improvements Collaborates with internal departments to facilitate claim processing and to come to appropriate claim resolutions Responds to claim questions and concerns Prepares claims for Medical Director review by completing required documentation and ensuring all pertinent medical info is attached Possess a general knowledge and understanding of CareSource claim payment edits Analyze and identify trends in high scoring