Fraud Analyst

JOB OVERVIEW

Reporting to the Fraud Investigations Lead, the Fraud Analyst is a specialized, forensic investigator responsible for identifying, analyzing, and mitigating financial leakage stemming from fraudulent activities, waste, and abuse across regional healthcare networks. The Analyst owns the end-to-end investigation of suspicious medical portfolios, profiles high-risk healthcare providers, and compiles formal fraud assessment reports for executive stakeholders.

This role combines clinical-financial forensics with risk engineering, designing proactive operational controls, developing anti-fraud awareness materials, and collaborating closely with Global Operations to ensure the consistent application of the corporate Fraud Framework.

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KEY RESPONSIBILITIES

Responsibilities will include, but are not limited to, the following:

• Identify & investigate fraudulent activities and present fraud reports to the relevant stakeholders
• Participate in the role of Auditing in line with Operations Auditing Practices.
• Review and assess regions, providers & other areas of risk to identify potential fraud or misrepresentation.
• Identify & report cost containment opportunities
• Identify areas of fraud risk & assist with the design & implementation of controls to mitigate that risk.
• Provide input into Operations Controls to achieve acceptable cost containment & fraud identification standards
• Create & facilitate Anti-Fraud Awareness & support material as required
• Liaise with Global Operations Functions to ensure consistency in the application of the Global Claims Fraud Framework
• Respond to client enquiries accurately and professionally and when necessary, liaise with additional departments to ensure an efficient response is given thereby achieving client satisfaction.
• Other Ad hoc duties as required

REQUIREMENTS

To be successful in this position you will need to have the following skills / experience:

Essential

• Bachelor’s degree in any Medical field, Paramedical, Finance, Business Administration, Insurance, or a related technical discipline is preferred.
• Minimum of 2 years of experience in a customer-focused environment, specifically within clinical/paramedical functions, a TPA, or the health insurance operations floor.
• Demonstrated experience analyzing and assessing high-value, highly complex medical claims portfolios for technical or clinical variances.
• Proficiency inside the MS Office suite (specifically advanced Excel for data tracking, Power BI for metric visualization dashboards, and PowerPoint for summary framing).