LTC Fraud Consultant
New
United StatesFull-TimeMiddle
Salary$73,350.00 USD - $122,250.00 USD
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Job Details
- Experience
- 3–5 years
- Required Skills
- SQLBusiness AnalysisData AnalysisMicrosoft Power BITableauMicrosoft Excel
Requirements
- 3–5 years of experience in Long-Term Care (LTC), healthcare/insurance business analysis, and/or Fraud, Waste & Abuse (FWA)
- Strong analytical and critical-thinking skills; able to interpret complex claims and operational data
- Ability to translate findings into clear artifacts (business requirements, user stories, process flows)
- Advanced Excel skills and comfort with large datasets
- Familiarity with SQL/SAS and/or BI tools (Power BI/Tableau) a plus
- Clear written and verbal communicator; able to work effectively with both technical and non-technical stakeholders
- Experience with fraud investigations/SIU preferred
- Familiarity with Medicaid and/or commercial LTC benefits and fraud/case management tools preferred
Responsibilities
- Lead targeted customer outreach to explain updated claim reimbursement controls, drive adoption, and support understanding and compliance.
- Spend approximately 60% of the role on the phone conducting customer outreach related to claim reimbursement controls, education, and support.
- Analyze LTC claims and provider billing patterns to identify potential fraud, waste, and abuse.
- Prepare data extracts, dashboards, and concise analytic summaries to support case development and investigations.
- Monitor and communicate emerging fraud schemes; help design mitigations, controls, and process improvements.
- Partner cross-functionally with investigators, clinical teams, and technology teams to improve fraud operations and detection capabilities.
- Gather and document business needs (requirements, user stories, process flows) for enhancements to fraud detection and case management tools.
- Support performance monitoring and reporting for the LTC FWA program, and contribute to continuous improvement across fraud operations.
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