Medicaid Fraud, Waste & Abuse Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Utilize established FWA analytic models to assess Medicaid claims data for potential fraud, waste, and abuse.

• Generate monthly, prequalified FWA lead referral reports.

• Create clear, defensible, and audit-ready reports that detail analytic rationale, suspected behavior, and relevance to investigations.

• Present FWA lead referrals to state Medicaid program integrity teams and OIG staff.

• Clarify findings, methodologies, and data sources to support state investigations.

• Address follow-up inquiries and conduct supplemental or ad hoc analyses as necessary.

• Assist in investigations by providing documentation, exhibits, and data interpretation.

• Attend meetings and briefings, offering testimony or in-person investigative support as required.

• Travel for fraud investigations, hearings, or related activities as necessary.

• Offer feedback to analytics and data science teams regarding model performance and data quality.

• Suggest enhancements, modifications, or corrections to analytic models.

• Convert state feedback and investigative results into prioritized items for the analytics roadmap.

• Evaluate additional audit program outcomes to identify systemic vulnerabilities in program integrity.

• Formulate data-driven recommendations regarding claims adjudication processes, controls, or edits.

• Provide guidance to states on policy, regulatory, or statutory changes aimed at reducing FWA risk and addressing program gaps.

⛳️ Requirements

• Over 5 years of extensive experience in analyzing Medicaid claims and encounter data to detect fraud, waste, and abuse.

• More than 5 years of in-depth knowledge of Medicaid program integrity, including prevalent FWA schemes, audit methodologies, and investigative workflows.

• At least 4 years of experience preparing reports and presentations that document analytic methods and results for both internal and external stakeholders.

• Proficient in reading, interpreting, and applying Medicaid policy, regulations, state plan language, and relevant guidance.

• Excellent written and verbal communication skills.

• Experience in presenting analytic findings to state agencies, Offices of Inspector General, or other oversight bodies.

• Video cameras are required to be used during all interviews and for the first week of orientation.

🏝️ Benefits

• Flexible work arrangements.

• Opportunities for learning and career development.

• Access to technical credentials and certifications.

• A generous and flexible vacation policy.

• Educational assistance.

• Leadership and technical development academies.

• Employer match on 401(k) contributions.

• Comprehensive health benefits.

• Equal Opportunity Employer.