Senior Program Integrity Analyst

🔥 2 minutes ago

🇺🇸 United States – Remote

💵 $155k - $165k / year

⏰ Full Time

🟠 Senior

📋 Program Manager

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HHAeXchange

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2008

🏥 Healthcare

💼 Consulting

📦 Logistics

💰 Private Equity Round on 2021-09

Healthcare • Consulting • Logistics

HHAeXchange is a comprehensive homecare software solution that connects different stakeholders in the homecare industry, including providers, state Medicaid programs, managed care organizations (MCOs), and caregivers. It offers a platform that ensures efficiency, communication, transparency, and compliance in managing homecare services. With tools for EVV (Electronic Visit Verification), billing, payroll, scheduling, and a caregiver mobile app, HHAeXchange improves care outcomes and operational efficiency. The platform is secure and scalable, integrating various business functions for better visibility and efficiency, and is designed to support value-based care initiatives. HHAeXchange aims to streamline homecare service delivery, reduce errors, and enhance caregiver experiences.

📋 Description

• 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.

🎯 Requirements

• 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.

🏖️ Benefits

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