Program Integrity Data Analyst

CSRA   •  

Menands, NY

Industry: Professional, Scientific & Technical Services


5 - 7 years

Posted 179 days ago

This job is no longer available.

Position Overview

The Fraud/Data Analyst will explore new techniques to identify patterns of fraud, waste and abuse and other forms of improper payments.  This will include a review of the current fraud control procedures and develop ways to identify and measure the impact of fraud.  The Fraud/Data Analyst will analyze Medicaid claims and medical records to determine suspicious patterns of billing and illegal activity. She/He will review claims utilizing records and system reports to determine proper documentation, utilization and appropriateness of services to identify possible fraud and abuse.  Further, the Fraud/Data Analyst will work as part of a team to detect fraud, report fraud alert schemes, including providers and supportinvestigation of Medicaid fraud cases. She/He will stay current with fraud trends and analytical procedures. The Medicaid Fraud Analyst will act in concert with the state Fraud Control Units including the Office of Health Insurance Programs, the Office of the Medicaid Inspector General, and where appropriate the Medicaid Fraud Control Unit within the Office of the Attorney General, and state and local authorities.

Required experience criteria:

  • BA or equivalent + 6 yrs related experience, or MA + 4 yrs related experience

  • Medicaid programs and policies, auditing procedures and claims processing systems
  • Medical claimssampling and data collection procedures
  • Reviewing Medicaid provider information and enrollment applications
  • Generating reports detailing fraud detection and prevention activities
  • Reviewing medical claims to determine proper and improper billing
  • Knowledge of correct coding of medical procedures
  • Demonstrate expertise in reviewing claims and making appropriate decisions to detect fraud
  • Knowledge of medical terminologies like International Classification of Diseases (ICD) Version 10
  • Bachelor’s degree in accounting, healthcare administration, healthcare management, management information systems or related field
  • Microsoft Excel and Word
  • Six (6) years’ experience in Medical Claims processing / auditing

Preferred experience criteria:

  • Certification as Computer Information Systems Auditor
  • Membership in a National association associated with combating healthcare fraud and abuse, such as the Systems Audit and Control Association, National Association of Medicaid Fraud Control Units, or National Healthcare Anti-Fraud Association
  • Experience working with data in State Medicaid Data Warehouses
  • Knowledge of coding medical claims from multiple healthcare delivery organizations and/or insurance carriers
  • Working knowledge of Analytic tools such as Bi Query or Oracle Reports
  • Experience in healthcare fraud investigation/detection
  • Ability to identify opportunities to improve processes and procedures