Fraud Investigation Analyst

At Zelis, we Get Stuff Done. So, let's get to it!

A Little About Us

Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients.

A Little About You

You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are.

Position Overview

The Fraud Investigation Analyst, Enterprise Fraud, will contribute significantly to safeguarding Zelis against fraudulent activities by conducting comprehensive reviews of all internal and external fraud monitoring alerts, performing fraud investigations, and thoroughly documenting all findings and outcomes. In this role, you will be expected to provide timely updates on observed fraud trends and emerging patterns to assist Enterprise Fraud in developing fraud strategies and suspicious activity monitoring.

Collaboration is key in this position, as you will work closely with various areas within Zelis, including Payments Optimization, Price Optimization, Insights & Empowerment, Compliance, and People & Culture. Your ability to combine an extensive set of investigative skills with your knowledge of Zelis and our products, services, and clients, will be put to the test on a daily basis.

This role requires keen analytical skills, a passion for preventing wrong-doing, and a fervent curiosity to investigate in order to support Enterprise Fraud in prevention, detection, reporting, and monetary recovery related to financial fraud and healthcare fraud, waste, and abuse.

What You'll Do

Perform reviews and detailed link analysis utilizing various tools and reports to identify internal or external fraudulent activity, including potential Fraud, Waste, and Abuse (FWA), across all Zelis business units and functions.

Initiate fraud investigations and handle all aspects, including detailed documentation, analysis, research, summaries and case management within the appropriate tracking systems to ensure information is accurate and timely.

Examine public record databases, open-source records, statements, invoices, correspondence, device data and other records pertaining to the transactions, events, financial crimes, or other incidents under investigation.

Develop working relationships and communicate with federal, state, and local officials, and other organizations and individuals related to investigations for the purpose of gathering facts, obtaining statements, learning sequences of events, obtaining explanations, and otherwise advancing investigative objectives.

Through regular participation in industry groups and associations, maintain up-to-date knowledge and awareness of best practices in fraud detection and prevention, investigative fraud techniques, fraud industry trends, and significant fraud events.

Identify and recommend policy, procedure and system changes to enhance investigative outcomes and performance.

Contribute to the creation and updating of Enterprise Fraud documentation (e.g. Standard Operating Procedures) and data repositories (e.g. Known Fraud Data Negative List.)

On limited occasions, conduct investigations after hours or on weekends for escalated or high-priority Fraud events.

What You'll Bring to Zelis

Bachelor's degree is required, preferably in Criminal Justice, Finance, Accounting, or Business Administration.

4+ years of experience related to fraud prevention, financial services, risk management, or compliance, preferably in the healthcare industry.

Professional industry certification as a Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), Health Care Anti-Fraud Associate (HCAFA), Certified Financial Crimes Investigator (CFCI), or Certified Financial Crime Specialist (CFCS), preferred.

Proficient knowledge of Microsoft Excel, Word, PowerPoint, and case management or case review applications.

Strong logical, analytical, and critical thinking skills, paired with a willingness to solve problems using creativity and innovation.

Ability to effectively determine fraud risk while remaining objective and separating facts from opinions.

Demonstrate high ethical standards that drive initiative, excellent follow-through, and persistence in locating and securing needed information.

Effective organizational, communication, and interpersonal skills with a demonstrated ability to foster collaborative work partnerships with individuals at all levels.

Ability to multi-task, adapt quickly to changing priorities, and operate effectively across geographic and functional boundaries to meet tight deadlines.

Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.

Location and Workplace Flexibility

We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies.

Base Salary Range

$71,000.00 - $95,000.00

At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role.

Zelis' full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees' health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage.

Equal Employment Opportunity

Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.

Accessibility Support

We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and / or interview process, please email TalentAcquisition@zelis.com .

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.