Senior Fraud Investigator: Medicaid Analytics

University of Massachusetts Medical School; Westborough (MA); On-site; USD 70,000 - 100,000; Full time

Job summary

The University of Massachusetts Medical School seeks a Fraud Investigator II to lead Medicaid fraud investigations, performing data mining, data analysis and complex case reviews under supervision. You will identify aberrant billing patterns, develop reports and assist with investigations across provider types.

Based in Westborough, MA, this role requires travel to the office about twice per month and involves coaching junior staff, communicating findings to providers, and recommending system

Qualifications

• Bachelor’s degree in business administration, finance, public health or related field, or equivalent experience.
• 5–7 years related experience in fraud examination, healthcare, business, finance or related field; with at least 2 years data mining in healthcare insurance.
• Knowledge of coding, reimbursement and claims processing policies.
• Knowledge of medical auditing principles.
• Strong analytical and problem-solving skills with attention to detail.
• Knowledge of fraud regulations and ability to apply them.
• Ability to multi-task and work independently under pressure.
• Proficiency with Microsoft Office applications (Word, Excel, PowerPoint, Access).
• Excellent customer service, communication, and interpersonal skills.
• Strong oral and written communication abilities.

Responsibilities

• Apply in-depth knowledge of federal and state regulations and healthcare industry standards.
• Conduct independent data mining and data analysis using claims data to detect aberrancies and trends.
• Develop algorithms, queries, and reports to detect potential FWA activity.
• Analyze member records and claims data to ensure regulatory compliance.
• Develop investigative reports, document findings, calculate overpayments, and issue findings per policies.
• Document work and audit results per standards and guidelines.
• Communicate findings with providers regarding audits and recoveries.
• Recommend policy, procedure and system changes to improve outcomes.
• Determine compliance with Medicaid regulations by examining records.
• Mentor Investigator I staff on recognizing fraudulent patterns.
• Serve as a resource for departments on integrity inquiries.
• Update management on progress and propose new algorithms.
• Create, maintain and manage cases in tracking systems.
• Perform other duties as needed.

Skills

Fraud investigations

Data mining

Data analysis

Regulatory compliance

Analytical thinking

Problem solving

Attention to detail

Communication skills

Multi-tasking

Interpersonal skills

Education

Bachelor’s degree in business administration/finance/public health or related field

Tools

SQL

Excel

Access

PowerPoint

Job description

The University of Massachusetts Medical School seeks a Fraud Investigator II to lead Medicaid fraud investigations, performing data mining, data analysis and complex case reviews under supervision. You will identify aberrant billing patterns, develop reports and assist with investigations across provider types.

Based in Westborough, MA, this role requires travel to the office about twice per month and involves coaching junior staff, communicating findings to providers, and recommending system