Senior Program Integrity Analyst

🕒 Agosto 5

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $155.000 - $165.000 / ano

⏰ Tempo Integral

🟠 Sênior

🧐 Analista

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HHAeXchange

SiteLinkedInTodas as Vagas

501 - 1000 funcionários

Fundada em 2008

🏥 Saúde

💼 Consultoria

📦 Logística

💰 Private Equity Round em 2021-09

Healthcare • Consulting • Logistics

HHAeXchange é uma solução abrangente de software para cuidados domiciliares que conecta diferentes partes interessadas na indústria de cuidados domiciliares, incluindo prestadores, programas estaduais de Medicaid, organizações de cuidado gerenciado (MCOs) e cuidadores. Oferece uma plataforma que garante eficiência, comunicação, transparência e conformidade na gestão de serviços de cuidados domiciliares. Com ferramentas para EVV (Electronic Visit Verification), faturamento, folha de pagamento, agendamento e um aplicativo móvel para cuidadores, o HHAeXchange melhora os resultados do cuidado e a eficiência operacional. A plataforma é segura e escalável, integrando várias funções de negócios para melhor visibilidade e eficiência, e é projetada para apoiar iniciativas de cuidados baseados em valor. O HHAeXchange visa simplificar a prestação de serviços de cuidados domiciliares, reduzir erros e melhorar as experiências dos cuidadores.

Descrição

• Analyze Medicaid claims, visit, and EVV datasets to identify fraud, waste, or abuse patterns in home and community-based care. • Identify suspicious billing patterns including visit overlaps, impossible billing hours, upcoding, duplicate or unbundled claims, provider billing spikes, beneficiary identity issues, and EVV inconsistencies. • Distinguish fraud, waste, and abuse and recommend appropriate investigative or corrective responses. • Conduct proactive analysis to identify emerging fraud trends and systemic program integrity risks. • Apply Medicaid revenue-cycle knowledge to contextualize billing anomalies. • Translate analytical findings into business requirements for product and engineering teams, including detection signals, thresholds, and conditions. • Contribute to fraud detection dashboards, alerting systems, and investigation workflows. • Validate detection tools and analytical models, identifying false positives, coverage gaps, and missed risk categories. • Serve as the FWA and program integrity subject matter expert. • Present findings and insights to state Medicaid agencies, managed care organizations, and internal stakeholders. • Support customers with regulatory reporting, corrective actions, audit readiness, and program integrity outcomes. • Advise state and payer partners on CMS Medicaid Integrity Program standards and federal program integrity requirements. • Document analytical methodologies and investigation approaches for compliance reviews, audits, and reporting. • Contribute to customer discussions on detection strategy and program integrity priorities. • Perform other duties as assigned. • Travel up to 10%, including overnight travel.

🎯 Requisitos

• Bachelor’s degree and a minimum of 5 years experience in healthcare fraud detection, program integrity, payment integrity, SIU investigation, or a closely related field. • Substantive knowledge of how fraud, waste, and abuse manifests in healthcare billing data. • Working knowledge of Medicaid programs, including provider enrollment, service documentation, claims submission, and reimbursement. • Ability to recognize FWA patterns in healthcare claims or billing data and distinguish fraud, waste, and abuse in context. • Strong analytical thinking and investigative problem-solving skills. • Ability to communicate complex analytical findings to technical and non-technical audiences, including engineers, compliance officers, state regulators, and executives. • Ability to work with ambiguous or fragmented data architecture and reconcile information across multiple systems and tables. • Ability to proactively identify resources, data, and stakeholders in an evolving environment. • Working familiarity with data tools to query, explore, and validate analytical outputs independently. • Willingness to explore and adopt AI tools responsibly. • Preferred: experience with Medicaid HCBS, personal care services, or home care programs. • Preferred: familiarity with EVV data and 21st Century Cures Act EVV mandates. • Preferred: experience presenting fraud findings to regulators, compliance teams, legal, or law enforcement partners. • Preferred: exposure to AI or machine learning tools for healthcare fraud detection or payment integrity. • Preferred: CFE, AHFI, CHC, or CPC certification. • Preferred: experience with Python, R, or data visualization/business intelligence tools.

🏖️ Benefícios

• Competitive health plans • Paid time-off • Company paid holidays • 401K retirement program with a Company elected match • Other company sponsored programs