Claims (FWA) Investigator - Healthcare
Location: Akron
Posted on: June 23, 2025
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Job Description:
SummaCare is a Summa Health entity that offers health insurance
in northern Ohio. As a regional, provider-owned health plan,
SummaCare is based in Akron, Ohio, and provides Medicare Advantage,
individual and family and commercial insurance plans. SummaCare has
one of the highest rated Medicare Advantage plans in the state of
Ohio, with a 4.5 out of 5-Star rating for 2025 by the Centers for
Medicare and Medicaid Services (CMS). Known for its excellent
customer service and personalized attention to members, SummaCare
is committed to building lasting relationships. Employees can
expect competitive pay and benefits. Summary: Conducts medium to
high complexity investigations under general supervision to
effectively pursue the identification, prevention, and
investigation of healthcare fraud, waste and abuse (FWA), to
facilitate the recovery of lost funds, and to comply with state and
federal regulations mandating fraud plans and practices. Skilled at
conducting analysis of claims data, medical records and claims
coding to identify aberrant patterns and support investigative
activities. Maintains knowledge of current schemes and determines
impact to the plan. Ensures the SIU processes and procedures
reflect current industry norms. Formal Education Required: a.
Bachelor’s Degree, or equivalent combination of education and
experience. Experience & Training Required: a. Five (5) years
health insurance experience to include: clinical review of medical
records, analysis, report development, database administration,
claims coding, and Fraud, Waste and Abuse identification and
investigation. b. Certified Professional Coder with one (1) years
of experience reviewing medical records c. Accredited Healthcare
Fraud Investigator (AHFI) certification preferred. d. Special
Investigations Unit (SIU) experience in a managed care setting. e.
LSS Yellow Belt Certified preferred. Other Skills, Competencies and
Qualifications: a. Demonstrate intermediate proficiency in MS
Office, Project, and database management. b. Maintain excellent
working knowledge of process improvement techniques, methodologies
and principles applying these in the normal course of operations.
c. Demonstrate excellent analytical and problem-solving skills. d.
Effectively conduct statistical analyses and accurately work with
large amounts of data. e. Apply principles of logical thinking to
define problems, collect data, establish facts, and draw valid
conclusions. f. Organize and manage time to accurately complete
tasks within designated time frames in fast paced environment. g.
Maintain current knowledge of and comply with regulatory and
company policy and procedures. Level of Physical Demands: a. Sit
for prolonged periods of time. b. Bend, stoop, and stretch. c. Lift
up to 20 pounds. d. Manual dexterity to operate computer, phone,
and standard office machines. Equal Opportunity
Employer/Veterans/Disabled $27.82/hr - $41.73/hr The salary range
on this job posting/advertising is base salary exclusive of any
bonuses or differentials. Many factors, such as years of relevant
experience and geographical location are considered when
determining the starting rate of pay. We believe in the importance
of pay equity and consider internal equity of our current team
members when determining offers. Please keep in mind that the range
that is listed is the full base salary range. Hiring at the maximum
of the range would not be typical.
Keywords: , Warren , Claims (FWA) Investigator - Healthcare, Healthcare , Akron, Ohio
