Medicaid Fraud, Waste & Abuse Analyst

🔥 3 minutes ago

🇺🇸 United States – Remote

💵 $69.4k - $99.2k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

📦 Logistics

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Consulting • Logistics • Healthcare Insurance

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• Apply established FWA analytic models to Medicaid claims data to identify potential fraud, waste, and abuse • Deliver monthly, prequalified FWA lead referral reports • Produce clear, defensible, audit-ready reports explaining analytic rationale, suspected behavior, and investigative relevance • 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 • Support investigations through documentation, exhibits, and data interpretation • Participate in meetings and briefings, and provide testimony or in-person investigative support as needed • Travel for fraud investigations, hearings, or related activities as required • Provide feedback to analytics and data science teams on model performance and data quality • Recommend enhancements, modifications, or corrections to analytic models • Translate state feedback and investigative outcomes into prioritized analytics roadmap items • Analyze other audit program outcomes to identify systemic program integrity vulnerabilities • Develop data-driven recommendations related to claims adjudication processes, controls, or edits • Advise states on policy, regulatory, or statutory changes to reduce FWA risk and close program gaps

🎯 Requirements

• 5+ years of extensive experience analyzing Medicaid claims and encounter data to identify fraud, waste, and abuse • 5+ years of deep knowledge of Medicaid program integrity, including common FWA schemes, audit methodologies, and investigative workflows • 4+ years preparing reports and presentations documenting analytic methods and results for internal and external customers • Experience reading, interpreting, and applying Medicaid policy, regulations, state plan language, and related guidance • Strong written and verbal communication skills • Experience presenting analytic findings to state agencies, Offices of Inspector General, or other oversight bodies • Video cameras must be used during all interviews and the initial week of orientation

🏖️ Benefits

• Work flexibility • Learning and career development • Technical credentials and certifications • Generous, flexible vacation policy • Educational assistance • Leadership and technical development academies • 401(k) employer match • Comprehensive health benefits • Equal Opportunity Employer