Data Analysis - Medicare/Medicaid Fraud Subject Matter Expert

Job Summary

As a Data Analyst II, you will conduct thorough evaluations and advanced analyses of potential fraud cases and data inquiries by leveraging claims information and multiple data sources. Provide critical support in developing complex, high-value, or sensitive cases that warrant referral to law enforcement, recovery of overpayments, or administrative action—driven by both proactive and reactive data analysis strategies.

Essential Duties and Responsibilities

·     Work with management, investigators, and analysts to provide key statistical research, analytics, and reporting functions for reactive and proactive case development support and to fulfill law enforcement data requests.

·     Communicate effectively with internal and external customers, including federal law enforcement officers.

·     Perform comprehensive analysis of healthcare claims data using advanced statistical and analytical methods; prepare clear, concise, and well-structured reports summarizing key findings.

·     Collaborate with management, investigators, and analysts to support both proactive and reactive case development efforts by fulfilling data requests.

·     Utilize data analysis techniques such as data mining, statistical modeling, predictive modeling, etc. to detect aberrancies in Medicare/Medicaid claims data, and proactively seek out and develop lead and cases received from a variety of sources including CMS and OIG, fraud alerts, and referrals from government and private sources. 

·     Work with Statisticians and Data Analysts t provide proactive data analysis results with statistically high probabilities of producing case referrals to law enforcement, overpayments, and/or administrative actions. 

·     Validate data analysis results and analytically identify potential fraud, waste and/or abuse situations in violation of Medicare/Medicaid laws, guidelines, policies and regulations. 

·     Communicate analytical insights effectively to internal stakeholders and external partners, including law enforcement agencies.

·     Support management requests for CMS reporting requirements.

·     Prepare, develop and participate in provider, beneficiary, law enforcement, or staff training as related to Medicare/Medicaid fraud, waste and/or abuse data analysis.

·     Demonstrate strong organizational skills and manage multiple tasks efficiently while adhering to strict timelines.

·     Ensure the integrity and security of all documentation by maintaining proper chain of custody and following confidentiality protocols.

·     Adhere to all required documentation standards and reporting procedures as defined by internal and external guidelines.

·     Perform other duties as assigned

Competencies

• High proficiency level with MS Word and Excel.
• Proficiency with database programming languages such as SQL, SAS and/or other applications to perform diverse types of data analysis.
• Demonstrated experience in handling large data sets and relational databases.
• 2 years’ experience in SQL or SAS experience as well as demonstrated knowledge of healthcare and claims, or a combination of education and equivalent work experience.
• Working knowledge of Python. 
• Demonstrated knowledge of various database management systems in order to input, extract or manipulate information.
• Exceptional organizational, communication, and problem-solving skills.

Preferred Qualifications

• Knowledge of Medicare and Medicaid rules and regulations, CMS reporting and fraud detection protocols a plus.
• Strong understanding of healthcare claims, ICD-9-CM and ICD-10-CM codes, physician specialty codes, pharmaceutical data, provider identifiers, and Medicare/Medicaid billing practices.
• Experience in transitioning from SAS to more modern tools (e.g., Databricks, Snowflake).

Education and Experience

·     Bachelor’s Degree in Mathematics, Statistics, Healthcare Administration, Data Science, or related discipline with preference given to MA or MS recipients, and/or relevant work experience as a data analyst

·     2 years of SQL or SAS development experience as well as demonstrated knowledge of healthcare and claims, or a combination of education and equivalent work experience

·     Demonstrated knowledge of various database management systems in order to input, extract or manipulate information

·     Demonstrated experience and knowledge of healthcare information (health claims data; specifically, Medicare and Medicaid, ICD-9-CM and ICD-10-CM codes, physician specialty codes, pharmaceutical data, provider identifiers, etc.) is preferred.

  Salary/Benefits

     The salary range for this role is TBD and negotiable commensurate with experience, education, qualifications,

     certification, geographic location and business or organizational needs.     

     Benefits include Medical, Dental & Vision, Life, LTD and STD, 401(k) with company match and paid    

     time off.