Fraud Investigation Analyst

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.