Fraud Analyst III

Availity delivers revenue cycle and related business solutions for health care professionals who want to build healthy, thriving organizations. Availity has the powerful tools, actionable insights and expansive network reach that medical businesses need to get an edge in an industry constantly redefined by change.

Job Overview:

We are seeking a detail-oriented and analytical Fraud Analyst III to join our team. In this role, you will play a critical part in safeguarding our organization against fraudulent activities. You will analyze patterns, identify vulnerabilities, and implement strategies to mitigate risks while ensuring compliance with healthcare regulations.

Key Responsibilities:

• Fraud Detection and Prevention: Monitor transactions and user behavior to identify suspicious activities and potential fraud schemes.
• Data Analysis: Conduct thorough analyses of data to uncover trends, patterns, and anomalies that indicate fraudulent behavior. Develop sophisticated KPIs to aid in tracking existing risk factors and operational impact. Coordinate with Management regarding potential front-end and back-end enhancements to further integrate anti-fraud measures and anti-fraud research capabilities.

• Investigative Reporting: Prepare comprehensive reports detailing findings, patterns of fraud, and recommendations for prevention strategies. Lead Incident response efforts for cyberfraud alerts on a 24x7 basis as part of our on-call rotation schedule.
• Collaboration: Work closely with cross-functional teams, including Compliance, Legal, and IT, to develop and implement fraud prevention measures. Serve as high level escalation support for the Availity Client Services contact center and their leadership team.

• Regulatory Compliance: Ensure adherence to healthcare regulations and standards, maintaining compliance with HIPAA and other relevant laws.
• Risk Assessment: Evaluate existing products, policies and procedures for vulnerabilities, recommending enhancements to mitigate risks. Interview suspected fraudsters and their victims to provide objective threat analyses.

Qualifications:

• Bachelor’s degree in Finance, Business, Criminal Justice, Computer Science, or a related field.
• 3+ years of experience in fraud analysis, risk management, or a related area, preferably in the healthcare or technology sector.
• 3-5 Years of Experience directly relevant to incident response and/or ad hoc research using SQL or Splunk.
• 3-5 years of experience using SQL (including variant languages), and demonstrates the ability to interpret, create and modify sophisticated ad-hoc queries during the incident response process.
• 1-3 years of experience using Splunk and demonstrate ability to manipulate queries in Splunk’s proprietary Search Processing Language (SPL).
• 1-3 years of experience using AWS toolsets to perform ad hoc research.
• 1-3 years of experience using PowerBI, Cognos, Splunk, and/or Apptrinsic/Gainsight for reporting.
• Strong analytical skills with proficiency in data analysis tools and methodologies including use of the Mitre Att&ck framework for defining fraudster tactics, techniques and procedures.
• Familiarity with business and healthcare regulations, compliance standards, and fraud detection techniques including those under the purview of HHS, CMS, FTC, SEC, HITRUST, NIST, and GDPR, including HIPAA, HITECH, and the NPI FINAL RULE.
• Excellent communication skills, both verbal and written, with the ability to present complex information clearly.
• Adept in investigative communication strategies for interactions with victims and fraudsters.
• Detail-oriented with strong problem-solving skills and the ability to work independently.

Preferred Qualifications:

• Certifications such as Certified Fraud Examiner (CFE), Certified Financial Crime Specialist (CFCS), CompTIA Security+.
• Experience with cybersecurity and fraud detection software and analytics platforms such as Anomali, Accurint, Plaid, Clear, Maltego, and/or Human Security.
• Experience working in a 24x7 operational environment, with geographic disparity.
• Experience with customer access administrator toolsets within Availity Essentials or other Availity products and services.
• Experience interpreting HIPAA ANSI X12 Electronic Data Interchange formatted transactions at a basic level.
• Experience developing and implementing basic automations using PowerShell and/or Python, with the ability to interact with and integrate applicable APIs.
• Ability to read, speak and interpret multiple languages to and from English at a business level, including any of the following: Spanish, French, Hindi, Bengali, Urdu, Russian, and/or Mandarin Chinese

Availity is an equal opportunity employer and makes decisions in employment matters without regard to race, religious creed, color, age, sex, sexual orientation, gender identity, gender expression, genetic information, national origin, religion, marital status, medical condition, disability, military service, pregnancy, childbirth and related medical conditions, or any other classification protected by federal, state, and local laws and ordinances.

Availity is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

NOTICE: Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. When required by state law or federal regulation, Availity uses I-9, Employment Eligibility Verification in conjunction with E-Verify to determine employment eligibility. Learn more about E-Verify at http://www.dhs.gov/e-verify.

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