ZipRecruiter

Log In

2

Remote Fraud Claims Jobs (NOW HIRING)

ITC Federal, Inc

Fraud Analyst

Fairfax, VA · Remote

Fraud Analyst Location US- ID 2026-1567 Remote Yes Overview JOB TITLE: Fraud Analyst AGENCY ... Familiarity with specific subject matter helpful - Medicare and Medicaid claims, student loan ...

New

ITC Federal, Inc.

Fraud Analyst

Remote CLEARANCE: Public Trust - Candidates do not need to be cleared at the time of application ... Familiarity with specific subject matter helpful - Medicare and Medicaid claims, student loan ...

New

Nymbus, Inc.

Fraud Analyst

We are a remote first company. This role, as most of our positions, is remote. You may be required ... claims of unauthorized activity related to Debit card, Credit card, ACH, P2P and Bill Payments ...

Nymbus, Inc.

Fraud Analyst

Jacksonville, FL · Remote

We are a remote first company. This role, as most of our positions, is remote. You may be required ... claims of unauthorized activity related to Debit card, Credit card, ACH, P2P and Bill Payments ...

TEEMA

Claims Reviewer

Phoenix, AZ · Remote

$25 - $29/hr

Arizona - Remote What you will be doing: * Conducts medical claims review using current claims ... Identifies and reports any potential quality or fraud issues to management, Quality Management, or ...

Medix

Remote Claims Representative

Dubuque, IA · On-site +1

$20 - $24/hr

Claims Representative (Remote) Location Requirements Candidates must reside in one of the following ... Evaluate claim details and identify potential fraud concerns when appropriate * Negotiate ...

Allied Benefit Systems

Be Seen First

Remote Medical Claims Specialist

Chicago, IL · Remote

$48K - $50K/yr

... fraud * Process claims in the QicLink System * Review, analyze and add applicable notes to the ... Remote Here at Allied, we believe that great talent can thrive from anywhere. Our remote friendly ...

TEEMA

Claims Reviewer

Phoenix, AZ · Remote

$26.40 - $27.88/hr

Identify opportunities for process improvement and flag quality or fraud concerns. * Support peers ... Eligible Locations The position is remote, but you can only reside in the following states: AK, AR ...

TMS

AI Architect- Insurance domain

Edison, NJ · Remote

$75/hr

Remote/ EST Experience: 15+ years overall; 4+ years in AI/ML architecture/engineering Role Summary ... claims, fraud, and operations. You will define end-to-end AI architecture (data → model → MLOps ...

Manulife

LTC Fraud Consultant

Florida, NY · Remote

$73K - $122K/yr

Analyze LTC claims and provider billing patterns to identify potential fraud, waste, and abuse ... Referenced Salary Location USA, Massachusetts - Full Time Remote Working Arrangement Remote Salary ...

Manulife

LTC Fraud Consultant

New Hampshire, OH · Remote

$73K - $122K/yr

Analyze LTC claims and provider billing patterns to identify potential fraud, waste, and abuse ... Referenced Salary Location USA, Massachusetts - Full Time Remote Working Arrangement Remote Salary ...

Manulife

LTC Fraud Consultant

New York, NY · Remote

$73K - $122K/yr

Analyze LTC claims and provider billing patterns to identify potential fraud, waste, and abuse ... Referenced Salary Location USA, Massachusetts - Full Time Remote Working Arrangement Remote Salary ...

next page

Showing results 1-20

People also search for

All JobsFraud Claims JobsRemote Fraud Claims Jobs

Remote Fraud Claims information

See salary details

$30.5K

$64.6K

$90K

How much do remote fraud claims jobs pay per year?

As of Jun 7, 2026, the average yearly pay for remote fraud claims in the United States is $64,609.00, according to ZipRecruiter salary data. Most workers in this role earn between $51,000.00 and $75,500.00 per year, depending on experience, location, and employer.

What is the difference between Remote Fraud Claims vs Remote Fraud Analysts?

AspectRemote Fraud ClaimsRemote Fraud Analysts
CredentialsTypically requires claims processing or insurance certificationsUsually requires analytical or investigative certifications
Work EnvironmentCustomer service and claims processing platformsData analysis and fraud detection tools
Industry UsageInsurance, finance, e-commerceBanking, finance, e-commerce
Job FocusHandling claims related to fraud incidentsIdentifying and investigating fraudulent activities

Remote Fraud Claims roles focus on processing and managing claims related to fraud, often requiring claims or insurance certifications. Remote Fraud Analysts concentrate on analyzing data to detect and prevent fraud, needing analytical skills and certifications. Both roles operate remotely within finance and e-commerce sectors but differ in their core responsibilities and required credentials.

More about Remote Fraud Claims jobs
What cities are hiring for Remote Fraud Claims jobs? Cities with the most Remote Fraud Claims job openings:
What are the most commonly searched types of Fraud Claims jobs? The most popular types of Fraud Claims jobs are:
What states have the most Remote Fraud Claims jobs? States with the most job openings for Remote Fraud Claims jobs include:
What job categories do people searching Remote Fraud Claims jobs look for? The top searched job categories for Remote Fraud Claims jobs are:
Remote Fraud Claims jobs near you

Clinical Auditor/Analyst (Remote)- Fraud, Waste and Abuse

UPMC Senior Communities

Pittsburgh, PA • On-site, Remote

$32.85 - $56.83/hr

Full-time

Posted 3 days ago

Job description

UPMC Health Plan has an exciting opportunity for a Clinical Auditor/Analyst position in the Fraud, Waste & Abuse department. This is a full time position working Monday through Friday daylight hours and will be a remote position.
The Clinical Auditor/Analyst is an integral part of the Special Investigations Unit (SIU) and is responsible for conducting clinical audits and reviews regarding the analysis of care and services related to clinical guidelines, coding requirements, regulatory requirements, and resource utilization. The Clinical Auditor/Analyst creates, maintains and analyzes auditing reports related to their assigned work plan and communicates the results with management. Other responsibilities include but are not limited to analysis of controlled substance prescribing and utilization to identify potential clinical care issues, prepayment review of claims, and prepayment review of unlisted codes. Claims analysis and the use of fraud and abuse detection software tools will be an integral part of the function of this position. Responsibilities will involve working in collaboration with appropriate Health Plan departments including Quality Improvement, Legal, and Medical Management to facilitate the resolution of issue or cases. Responsibilities may involve multiple line of business focused reviews, or ad hoc reviews as needed; analysis of billing by providers/physicians, and providing trending, analysis and reporting of auditing data. The Clinical Auditor/Analyst will routinely interact with providers, law enforcement and/or regulatory entities in the course of their duties.
Experience in mental health claims review and laboratory claims review is highly preferred!
Responsibilities:
  • Respond to fraud, waste, and abuse referrals and/or complete data analysis and related audits as assigned.
  • Utilize fraud detection software to assess and monitor for potential FWA.
  • Review and analyze claims, medical records and associated processes related to the appropriateness of coding, clinical care, documentation, and health plan business rules.
  • Provide a clinical opinion for special projects or various issues including appropriate utilization of controlled substances, prescribing of controlled substances, or medically appropriate services.
  • Query medical and/or pharmacy claims and conduct a risk assessment by performing data analysis and applying applicable coding guidelines,
  • Health Plan policies and any applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD).Evaluate referrals from Pharmacy Benefit Manager (PBM) by analyzing medical and pharmacy claims and associated clinical documentation in HealthPlaNET, Mars, Epic and/or Cerner.
  • Complete audits by utilizing standard coding guidelines and principles and coding clinics to verify that the appropriate CPT codes/DRGs were assigned and supported in the medical record documentation.
  • Attend in person or virtual recipient restriction hearings.
  • Review Medical Pended Queue claims to understand and resolve claim referral issues through research and interaction with other Health Plan Departments including Medical Management, Medical Directors, various committees, and other appropriate Health Plan departments.
  • As necessary, assist in the development of new policies concerning future Health Plan payment of identified issue.
  • Assess, investigate and resolve low to intermediate issues.
  • Write concise written reports including statistical data for communication to other areas of UPMC Health Plan and to communicate with department heads for identification of various problem issues, how they affect the Health Plan, and to make recommendations for resolution of the issue.
  • Identify error trends to determine appropriate training needs and suggest modifications to company policies and procedures.
  • Conduct provider education, as necessary, regarding audit results.
  • Communicate effectively with Medical Directors and ancillary departments as necessary to address issues and concerns.
  • Understand customers including internal Health Plan Departments (i.e. Claims staff, Customer Service, Marketing, etc.) and external customers (i.e. Health System Internal Audit, Client Audit teams) to understand issues, identify solutions and facilitate resolution.
  • Serve as an SIU representative at internal and external meetings, document and present findings to SIU Staff and document as appropriate in the SIU FWA Case Management Database.
  • Assist in the development and revision of SIU policies and procedures.
  • Identify trends for improvements internally, such as claims payment, to determine appropriate training needs and suggest modification to company policies and procedures.
  • Participate in training programs to develop a thorough understanding of the materials presented.
  • Obtain CPE or CEUs to maintain nursing license, and/or professional designations.
  • Design and maintain reports, auditing tools and related documentation.
  • Maintain or exceed designated quality and production goals.
  • Maintain employee/insured confidentiality and adhere to HIPAA regulations.

Qualifications:
  • Registered Nurse (RN).
  • Five years of clinical experience.
  • Two years of fraud & abuse, auditing, case management, quality review or chart auditing experience required.
  • Ability to analyze data, maintain designated production standards, and organize multiple projects and tasks.
  • In-depth knowledge of medical terminology, ICD-10 and CPT-4 coding. Knowledge of health insurance products and various lines of business.
  • Detail-oriented individual with excellent organizational skills.
  • Keyboard dexterity and accuracy.
  • High level of oral and written communication skills.
  • Proficiency with Microsoft Office products (Excel, Access, OneDrive, OneNote and Word).
    Licensure, Certifications, and Clearances:
    AAPC or AHIMA Certified (CPC, CPMA, CIC, CCA, CCS, CCS-P) or AHFI designation preferred.
  • Registered Nurse (RN)

*Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.
UPMC is an Equal Opportunity Employer/Disability/Veteran

Apply