Senior Program Integrity Analyst

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

📋 Description

• Evaluate Medicaid claims, visit, and EVV datasets to detect patterns of fraud, waste, or abuse in home and community-based care.

• Recognize suspicious billing trends, such as visit overlaps, unrealistic billing hours, upcoding, duplicate or unbundled claims, provider billing spikes, beneficiary identity issues, and inconsistencies in EVV.

• Differentiate between fraud, waste, and abuse while suggesting suitable investigative or corrective measures.

• Perform proactive analyses to uncover emerging fraud trends and systemic risks related to program integrity.

• Utilize knowledge of Medicaid revenue cycles to contextualize billing irregularities.

• Convert analytical insights into business requirements for product and engineering teams, including detection signals, thresholds, and conditions.

• Contribute to the development of fraud detection dashboards, alerting systems, and investigation workflows.

• Validate detection tools and analytical models, identifying false positives, gaps in coverage, and overlooked risk categories.

• Act as the subject matter expert on FWA and program integrity.

• Present findings and insights to state Medicaid agencies, managed care organizations, and internal stakeholders.

• Assist customers with regulatory reporting, corrective actions, audit preparedness, and outcomes related to program integrity.

• Advise state and payer partners on CMS Medicaid Integrity Program standards and federal program integrity requirements.

• Document analytical methodologies and investigation strategies for compliance reviews, audits, and reporting purposes.

• Engage in customer discussions concerning detection strategies and program integrity priorities.

• Execute other assigned duties.

• Travel up to 10%, which may include overnight trips.

⛳️ Requirements

• A Bachelor’s degree and at least 5 years of experience in healthcare fraud detection, program integrity, payment integrity, SIU investigations, or a closely related field.

• Substantial understanding of how fraud, waste, and abuse appear in healthcare billing data.

• Familiarity with Medicaid programs, encompassing provider enrollment, service documentation, claims submission, and reimbursement processes.

• Capability to identify FWA patterns in healthcare claims or billing data and distinguish between fraud, waste, and abuse in context.

• Strong analytical and investigative problem-solving abilities.

• Proficiency in communicating complex analytical results to both technical and non-technical audiences, including engineers, compliance officers, state regulators, and executives.

• Skill in navigating ambiguous or fragmented data architectures and reconciling information across various systems and tables.

• Proactive in identifying resources, data, and stakeholders in a dynamic environment.

• Working knowledge of data tools for querying, exploring, and validating analytical outputs independently.

• Openness to exploring and responsibly adopting AI tools.

• Preferred: experience with Medicaid HCBS, personal care services, or home care programs.

• Preferred: familiarity with EVV data and the mandates of the 21st Century Cures Act pertaining to EVV.

• Preferred: experience in presenting fraud findings to regulators, compliance teams, legal entities, or law enforcement partners.

• Preferred: exposure to AI or machine learning tools focused on healthcare fraud detection or payment integrity.

• Preferred: certifications such as CFE, AHFI, CHC, or CPC.

• Preferred: experience with Python, R, or data visualization/business intelligence tools.

🏝️ Benefits

• Competitive health plans

• Paid time-off

• Company paid holidays

• 401K retirement program with a company elected match

• Other company sponsored programs