Senior Analyst, Payment Integrity Analytics

🕒 Maio 28

🤠 Texas – Remoto

🤠 Texas – Remote

💵 $69.400 - $99.200 / ano

⏰ Tempo Integral

🟠 Sênior

🧐 Analista

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Gainwell Technologies

SiteLinkedInTodas as Vagas

10.000+ funcionários

⚕️ Seguro de Saúde

💰 Grant em 2023-06

Healthcare Insurance • Human Services • Healthcare

A Gainwell Technologies é a principal provedora do país de soluções digitais e cloud-enabled em todo o ecossistema de serviços humanos e saúde pública. Com uma abordagem orientada por propósito, a Gainwell atende clientes nos 50 estados dos EUA, com foco em melhorar os desfechos em saúde e oferecer experiências intuitivas e centradas nas pessoas. Seu portfólio abrangente inclui modernização do Medicaid Enterprise, data analytics, serviços para prestadores e soluções para farmácia — tudo projetado para impulsionar o futuro da saúde e promover o bem-estar das comunidades.

Descrição

• 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).

🎯 Requisitos

• 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.

🏖️ Benefícios

• generous, flexible vacation policy • educational assistance • comprehensive health benefits • 401(k) employer match • leadership and technical development academies