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Remote Fraud Risk Management Jobs in Pennsylvania

Clark Associates

Director of Risk

Lancaster, PA · On-site +1

Lead the design, procurement, and ongoing management of all corporate insurance programs, including ... Remote Work Qualifications * Access to a reliable and secure high-speed internet connection. Cable ...

Bing Recruitment

Chief Risk Officer

Philadelphia, PA · On-site +1

$185K - $250K/yr

Remote; AL; CA; IL; FL; MA; NC; NJ; NY; PA; TX; UT; VA Pay Salary: $185,000-$250,000, bonus ... They develop risk management frameworks, ensure regulatory compliance, and report to the board.

Jj

Senior Analyst, Risk Intelligence

Horsham, PA · On-site +1

Risk Management Job Category: Professional All Job Posting Locations: Cambridge, Massachusetts ... Remote work options may be considered on a case-by-case basis and if approved by the Company. An ...

Munich Re

Senior Cyber and Tech Risk

Philadelphia, PA · On-site +1

Open to all HSB/Munich Re Offices + Remote Options Senior Cyber and Tech Risk About the Role ... Manage marketing efforts and track cyberrelated client management activities * Collaborate with ...

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Remote Fraud Risk Management information

How does a Remote Fraud Risk Management professional typically collaborate with cross-functional teams to mitigate risks?

Remote Fraud Risk Management professionals regularly work alongside departments such as IT, compliance, customer service, and legal to identify and address potential fraud threats. Collaboration often involves virtual meetings, sharing data insights, and developing joint strategies to detect suspicious activity. Effective communication and the ability to explain complex risk scenarios to non-specialists are crucial. This cross-functional teamwork ensures that fraud prevention measures are integrated throughout the organization and that responses to incidents are swift and coordinated.

What are the key skills and qualifications needed to thrive in Remote Fraud Risk Management, and why are they important?

To thrive in Remote Fraud Risk Management, you need strong analytical skills, attention to detail, and a background in finance, business, or a related field, often supported by relevant certifications such as CFE (Certified Fraud Examiner). Familiarity with fraud detection software, data analysis tools, and case management systems is typically required. Excellent communication, critical thinking, and problem-solving abilities set top performers apart in this role. These skills and qualities are essential for effectively identifying, preventing, and responding to fraudulent activities in a remote environment.

What is the difference between Remote Fraud Risk Management vs Remote Fraud Analyst?

AspectRemote Fraud Risk ManagementRemote Fraud Analyst
CredentialsCertifications in fraud prevention, risk management, or related fieldsBasic knowledge of fraud detection, often with certifications like ACFE or similar
Work EnvironmentStrategic, policy development, and oversight roles within organizationsOperational, investigative roles focused on analyzing transactions and detecting fraud
Employer & Industry UsageFinancial institutions, e-commerce, and fintech companiesBanking, online retail, and payment processing companies
Search & Comparison IntentUnderstanding strategic risk management roles in fraud preventionOperational roles focused on fraud detection and analysis

Remote Fraud Risk Management involves developing policies and overseeing fraud prevention strategies, while Remote Fraud Analysts focus on analyzing transactions to detect and investigate fraud. Both roles are essential in combating fraud but differ in scope and responsibilities.

What is Remote Fraud Risk Management?

Remote Fraud Risk Management refers to the processes and strategies used to detect, prevent, and respond to fraudulent activities in digital environments, especially when employees and operations are distributed or working remotely. This role involves monitoring transactions, analyzing data for suspicious patterns, and implementing security measures to minimize risks. Professionals in this field work closely with IT, compliance, and legal teams to ensure that systems and data remain secure despite the challenges of remote work. Effective remote fraud risk management is critical for protecting organizations from financial losses and reputational damage.
What are the most commonly searched types of Fraud Risk Management jobs in Pennsylvania? The most popular types of Fraud Risk Management jobs in Pennsylvania are:
What are popular job titles related to Remote Fraud Risk Management jobs in Pennsylvania? For Remote Fraud Risk Management jobs in Pennsylvania, the most frequently searched job titles are:
What job categories do people searching Remote Fraud Risk Management jobs in Pennsylvania look for? The top searched job categories for Remote Fraud Risk Management jobs in Pennsylvania are:
What cities in Pennsylvania are hiring for Remote Fraud Risk Management jobs? Cities in Pennsylvania with the most Remote Fraud Risk Management job openings:
Remote Fraud Risk Management 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 22 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.
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

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