Medicaid Program Integrity Analyst

New Mexico Department of Justice; Santa Fe (NM); On-site; USD 52,000 - 78,000; Full time

Job summary

The Business Operations Analyst will support the integrity of New Mexico's Medicaid program by reviewing allegations of provider fraud, waste, and abuse, conducting initial reviews, and coordinating with MCOs and partner agencies to ensure timely disposition and recovery of improper payments.

Document referrals, maintain confidential records, and communicate professionally with internal and external partners while adhering to privacy rules.

Qualifications

• Analytical mindset for evaluating claims, financial, health care, or compliance information.
• Ability to conduct research and document findings clearly.
• Strong written and verbal communication skills.
• Experience collaborating with internal staff, MCOs, providers, and investigative partners.
• Knowledge of Medicaid, health care billing, fraud, waste and abuse, program integrity or auditing is desirable.

Responsibilities

• Receive and evaluate allegations of Medicaid provider fraud, waste, and abuse from MCOs, state agencies, providers, members and other sources.
• Conduct initial reviews and research using claims systems and supporting documentation.
• Request additional information as needed and determine referrals.
• Document, assign, and track referrals and cases in program integrity systems; keep records complete and confidential.
• Coordinate referrals with MCOs and investigative or oversight entities; monitor through final resolution.
• Assist with Medicaid claims reviews, audits, and projects to identify overpayments and vulnerabilities.
• Support corrective actions and recovery of improper Medicaid payments per federal and state requirements.
• Communicate professionally while maintaining HIPAA compliance.

Skills

Analytical skills

Attention to detail

Organizational skills

Written communication

Verbal communication

Collaboration

Medicaid knowledge

Education

High school diploma

Tools

Medicaid claims systems

Case-tracking systems

Job description

The Business Operations Analyst will support the integrity of New Mexico's Medicaid program by reviewing allegations of provider fraud, waste, and abuse, conducting initial reviews, and coordinating with MCOs and partner agencies to ensure timely disposition and recovery of improper payments.

Document referrals, maintain confidential records, and communicate professionally with internal and external partners while adhering to privacy rules.