Senior Reconciliation & FWA Officer

Overview

A. Reconciliation Activities

• Perform and review reconciliations for claims payments, provider accounts, client accounts and related financial transactions.
• Investigate and resolve discrepancies, variances and unmatched items in a timely manner.
• Ensure accurate reconciliation of claims float, reserves, premiums and provider settlements.
• Coordinate with Finance, Claims and Operations teams to validate data and close issues.
• Maintain complete documentation and audit trails for reconciliation activities.

B. Fraud, Waste & Abuse (FWA) Monitoring

• Identify and support investigations of potential FWA cases related to claims and provider activities.
• Analyze claims patterns, billing trends and financial data to detect anomalies.
• Conduct preliminary investigations and escalate high‑risk or confirmed cases.
• Support implementation of FWA detection controls and monitoring tools.
• Collaborate with medical, compliance and internal stakeholders during investigations.

C. Reporting & Analysis

• Prepare reconciliation reports, discrepancy summaries and FWA analysis dashboards.
• Monitor key indicators related to financial accuracy and fraud risk.
• Provide insights and recommendations to enhance controls and reduce financial leakage.
• Support internal and external audit requirements.

D. Compliance & Internal Controls

• Ensure adherence to internal policies, procedures and regulatory requirements.
• Support continuous improvement of internal controls across claims and payment processes.
• Identify control gaps and recommend corrective and preventive actions.

E. Process Improvement & Coordination

• Recommend process enhancements to improve reconciliation efficiency and FWA detection.
• Coordinate with IT and system teams to improve data accuracy and reporting capabilities.
• Support staff training and awareness initiatives related to fraud prevention and financial controls.
• ***Qualifications & Experience:***

Education

• Bachelor’s degree in Accounting, Finance, Business Administration or a related field.
• Professional certifications (CPA, CMA, CIA, CFE) are an advantage.

Experience & Knowledge

• 5–8 years of experience in reconciliation, audit, finance operations or fraud investigation.
• Prior experience in healthcare insurance, TPA or claims environments is highly preferred.
• Strong understanding of claims processes, provider payments and financial workflows.
• Knowledge of fraud detection techniques, risk management and internal controls.

Core Competencies

• Strong analytical and investigative skills.
• High attention to detail and accuracy.
• Sound judgment, problem‑solving and critical‑thinking abilities.
• Ability to handle sensitive and confidential information.
• Clear communication and reporting skills.
• Proven ability to work cross‑functionally with Finance, Claims and Compliance teams.