ResponsibilitiesPeraton is seeking a Technical Project Manager to fulfill the role of a Fraud Analytics SME to serve as the healthcare program-integrity subject-matter authority on an agentic AI proof-of-concept team supporting the Fraud Prevention System Program (FPS2) program for CMS, driving fraud/waste/abuse use-case selection, ground-truth curation, and analyst-facing adoption. Working alongside AI engineers and investigators, the SME ensures AI-generated leads, dashboards, and case files reflect how Medicare and Medicaid fraud is actually detected, investigated, and adjudicated in the CMS program-integrity ecosystem.
Key Responsibilities
- Serve as the healthcare program-integrity and FWA subject-matter authority on the AI tool assessment project within FPS.
- Drive FWA use-case selection for the POC, prioritized by fraud impact and analyst value.
- Define and curate ground-truth datasets (known-bad-actor sets, adjudicated case outcomes, referral/enforcement outcomes) used to evaluate AI-generated leads and case files.
- Shape analyst-facing use of Peraton[X] (Peraton’s AI tool) and Rapid FI (Fraud Intelligence) so generated leads, dashboards, and case files match real UPIC/MEDIC/MFCU/FDOC investigator workflows.
- Evaluate AI-generated outputs for factual, clinical, and procedural accuracy; represent the analyst voice back to engineering.
- Partner with the Fraud Signals AI Engineer to validate Babel Street correlations against known fraud patterns, and with the Peraton[X] Support SME on user onboarding and training material.
Qualifications
- Minimum of 12 years with BS/BA; Minimum of 10 years with MS/MA; Minimum of 7 years with Ph.D.
- 5+ years working with Medicare and/or Medicaid claims data in a program-integrity, audit, investigative, or fraud-analytics role.
- Deep knowledge of healthcare FWA patterns: billing schemes, coding manipulation, identity/beneficiary fraud, provider collusion, DME/home-health/hospice/prescription typologies.
- Direct experience inside the CMS program-integrity ecosystem: UPICs, MEDICs, MFCUs, HHS-OIG, DOJ, and Federal/State task-force coordination.
- Demonstrated ability to define and curate ground-truth datasets or investigative reference sets used to evaluate fraud-detection outputs.
- Ability to translate investigator and analyst workflows into use cases and acceptance criteria for analytics or AI teams.
- Familiarity with FPS, IDR, One PI, UCM, or comparable CMS PI systems and their outputs (provider-risk scores, ASRs, model alerts, NCD policy references), enough to interpret them, not to build them.
- Comfort partnering with AI/analytics engineers without needing to write code — the SME provides domain judgment, not implementation.
- Excellent written and verbal communication; comfortable representing findings to CMS stakeholders and law-enforcement partners.
- US citizen with the ability to obtain a Public Trust clearance.
Nice to Have
- Certified Fraud Examiner (CFE) credential
- Prior work with UPICs, MEDICs, CPS, OIG, DOJ, or as a CMS analyst.
- Hands-on experience with SAP BusinessObjects (Web Intelligence) on Medicare/Medicaid universes, plus SAS, Snowflake/Snowsight, or Databricks.
- Exposure to agentic AI / LLM analyst tools and comfort using them to accelerate lead review and case building.
- Familiarity with T-MSIS and cross-state Medicaid data.
- Clinical, coding (CPT/HCPCS/ICD-10), or nursing background.
- Experience authoring analyst training material, job aids, or short training modules.
Target Salary Range$176,000 - $282,000. This represents the typical salary range for this position. Salary is determined by various factors, including but not limited to, the scope and responsibilities of the position, the individual’s experience, education, knowledge, skills, and competencies, as well as geographic location and business and contract considerations. Depending on the position, employees may be eligible for overtime, shift differential, and a discretionary bonus in addition to base pay.
