Senior Analyst, Payment Integrity Analytics
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Job Description
Senior Analyst managing fraud detection analytics for state Medicaid agencies. Collaborating on investigations and producing actionable intelligence for program integrity stakeholders.
Responsibilities:
- Apply established FWA analytic models to Medicaid claims data to identify potential fraud, waste, and abuse.
- Deliver monthly, prequalified FWA lead referral reports on a consistent and reliable cadence.
- Produce reports that clearly articulate the analytic rationale, suspected behavior, and investigative relevance of each lead.
- Ensure all outputs are defensible, audit-ready, and written for non-technical investigative and policy audiences.
- Present FWA lead referrals to state Medicaid program integrity and OIG staff.
- Explain findings, methodologies, and data sources in support of state investigations.
- Respond to follow-up questions and perform supplemental or ad hoc analyses related to specific referrals.
- Support investigations through documentation, exhibits, and data interpretation.
- Participate in meetings, briefings, and, as needed, provide testimony or in-person investigative support (travel may be required).
Requirements:
- Extensive experience analyzing Medicaid claims and encounter data to identify fraud, waste, and abuse. (5+ years)
- Deep knowledge of Medicaid program integrity, including common FWA schemes, audit methodologies, and investigative workflows. (5+ years)
- Prepare reports and presentations documenting analytic methods and results for internal and external customers (4+ years)
- Experience reading, interpreting, and applying Medicaid policy, regulations, state plan language, and related guidance.
- Strong written and verbal communication skills, with experience presenting analytic findings to state agencies, Offices of Inspector General, or other oversight bodies.
- Prior experience working directly with state Medicaid agencies and/or Offices of Inspector General is strongly preferred.
- Professional certifications such as Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), and/or Accredited Health Care Fraud Investigator (AHFI) are preferred.
Benefits:
- generous, flexible vacation policy
- educational assistance
- comprehensive health benefits
- 401(k) employer match
- leadership and technical development academies
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