Medicaid/Medicare Program Integrity Analyst II

Coventbridge Integrity Systems; Grove City (OH); Hybrid; USD 70,000 - 77,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

Life, LTD and STD paid by the employer

401(k) with company match

Paid Time Off and holidays

Tuition assistance

Job summary

CoventBridge Integrity Systems seeks a Medicaid/Medicare Program Integrity Analyst II for a REMOTE role. You will evaluate leads, complaints, and investigations to verify allegations of potential fraud and recommend administrative actions to protect programs.

This position reports to the Program Integrity Supervisor and can work from Grove City, OH or remotely from a home office. The role emphasizes data analysis, documentation, and collaboration with CMS and state agencies.

Qualifications

• High School Diploma or GED; college/technical degree preferred in related fields.
• CFE certification preferred.
• At least 1 year experience in Program Integrity investigation/detection.

Responsibilities

• Evaluate leads, complaints, and investigations to determine if further action is warranted.
• Conduct independent reviews of fraud or abuse cases.
• Utilize basic data analysis to detect aberrancies in Medicare/Medicaid claims data.
• Review claims and provider files to identify fraudulent billing patterns.
• Make fraud determinations using guidelines, manuals, and regulations.
• Maintain documentation related to investigations and leads.
• Prepare and submit external correspondence and reports; share findings with stakeholders.
• Mentor/train new Program Integrity staff.

Skills

Research skills

Organizational skills

Time management

Communication skills

Independent work

Multi-tasking

Education

High School Diploma or GED

CFE certification preferred

Job description

Overview

Medicaid/Medicare Program Integrity Analyst II - REMOTE

The Medicaid/Medicare Program Integrity Analyst II performs evaluation and development of leads, complaints, and/or investigations to verify allegations of potential fraud. Recommends and/or implements appropriate administrative actions.

In assuming this position, you will be a critical contributor to meeting CoventBridge Integrity Systems' objective: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse.

This position will report directly to the Program Integrity Supervisor and will work in our Grove City, OH office. If not local, remotely from a home office.

Responsibilities/ Requirements

Responsibilities:

• Perform evaluation and development of leads, complaints, and/or investigations to determine if further investigation and administrative actions are warranted
• Conduct independent reviews resulting from the discovery of situations that potentially involve fraud or abuse
• Utilize basic data analysis techniques to detect aberrancies in Medicare and Medicaid claims data, and proactively seeks out and develops leads/investigations received from a variety of sources (e.g., CMS, OIG, 1-800-MEDICARE, and fraud alerts)
• Review information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare and Medicaid policies and initiate appropriate action
• Make potential fraud determinations by utilizing a variety of sources such as internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid regulations, and the Social Security Act
• Compile and maintain documentation and information related to investigations, cases, and/or leads
• Participate in onsite audits in conjunction with investigation development
• Develop and prepare potential Fraud Alerts and program vulnerabilities for submission to CMS. Share information on current fraud investigations with other Medicare contractors and state Medicaid agencies, law enforcement, and other applicable stakeholders
• Prepare and submit external correspondence and reports, including, but not limited to, overpayment letters, fraud case referrals, suspensions, rebuttals, Medicare/Medicaid findings reports, and administrative action recommendations
• Submit suspension notifications to providers upon suspension approval
• Prepare and submit ADR letters to providers associated with requests for medical record requests or suspension overpayment determinations
• Serve as mentor/trainer to new Program Integrity staff
• Perform other duties as assigned by PI Supervisor or PI Manager that contribute to task order goals and objectives

Requirements:

• Excellent research and organization, prioritization, and time management skills
• Excellent verbal and written communication skills
• Ability to work independently with minimal supervision
• Ability to multi-task in a fast-paced environment
• Knowledge of statistics, data analysis techniques, and PC skills are preferred

Educational/Experience Qualifications:

• High School Diploma or G.E.D. equivalent, with preference given to those candidates who have successfully completed college or technical degree programs related to the position (e.g., Criminal Justice, Statistics, Data Analysis, etc.)
• Candidates with Certified Fraud Examiner (CFE) Certifications will be given priority consideration
• At least 1 year of experience in Program Integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions

Benefits

• Medical, Dental, Vision plans
• Life, LTD and STD paid by the employer
• 401(k) with company match up to 4%
• Paid Time Off and company paid holidays
• Tuition assistance after 1 year of service

The salary range for this role is $70,000 to $77,000 annually. This is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but not limited to, relevant education, qualifications, certifications, experience, skills, geographic location, performance, and business or organizational needs.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

At this time, CoventBridge is not considering candidates who require visa sponsorship, currently or in the future, including but not limited to H-1B, H-2B, E-3, TN, O-1, F-1 (OPT/CPT, or J-1 Visa Statuses.)

About Us:

CoventBridge Integrity Systems delivers investigative services, technology, and expertise that help healthcare and government organizations protect critical programs, strengthen oversight, and address fraud, waste, abuse, and operational risk.

CoventBridge Integrity Systems is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, caste, disability, veteran status, and other legally protected characteristics and maintains a drug-free workplace.

CoventBridge Integrity Systems is committed to the full inclusion of all qualified individuals. As part of this commitment, CoventBridge Integrity Systems will ensure that persons with disabilities are provided reasonable accommodations. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact: Human Resources; 888-932-7364; [e-mail].