SIU Fraud Analyst

8925 Mass General Brigham Health Plan Holding Company, Inc.; Somerville (MA); Hybrid; USD 64,000 - 93,000; Full time

Job summary

Mass General Brigham Health Plan is seeking a Fraud Analyst to build data analytics for the SIU, creating SQL queries against claims data and producing regulatory reports. The role supports Fraud Investigators with reports to identify potentially fraudulent, wasteful, or abusive claims.

The ideal candidate has SQL proficiency and healthcare fraud investigations experience, with hybrid work and a full-time schedule in Somerville, MA.

Responsibilities

• Develop and run reports to identify suspicious billing patterns and present findings to leadership.
• Analyze claims data to uncover anomalies using healthcare coding knowledge and fraud schemes.
• Conduct preliminary investigations with data analyses to assess merits of allegations.
• Document investigative steps with detail to support conclusions.
• Report fraud or program abuse discoveries to external parties as required by law or contract.
• Receive investigative requests from field staff and internal teams.

Job description

Job Summary

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. The Fraud Analyst is building data analytics for MGB Health Plan's Special Investigations Unit; this role uses data analytics for the SIU to find fraud leads. This includes creating SQL queries for known fraud schemes to run against claims data, ad hoc regulatory reporting, and creating reports to support Fraud Investigators. The ideal candidate is proficient in SQL and has a background in healthcare fraud investigations. The role will be responsible for creating, refining, and performing various analytic reports aimed at identifying potential fraudulent, wasteful, or abusive claim submissions. In addition to performing analytics, the position will be required to conduct preliminary research of identified providers or members to include public records, contracts, and social media review, among others. The analyst will be accountable for documenting analytic and research activities within concise reports or memoranda.

Essential Functions

• Develop and run reports, analyze data to identify suspicious billing patterns, assess the merits of allegations, and present those findings to leadership.
• Analyze claims data to find suspicious billing patterns and outliers, using knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerabilities.
• Conduct preliminary investigations to assess the merits of allegations through fact-gathering and analyses of data sets.
• Organize data and document preliminary investigative steps with a high level of detail and accuracy to clearly and concisely support investigative inferences, conclusions, and recommendations.
• Report discoveries of fraud or program abuse to external parties, as required by law, rule, or contract.
• Receive investigative requests from field staff, internal claims associates, and underwriting.

Qualifications

• Education: Bachelor's Degree
• Experience: At least 2-3 years of experience investigating claims or compliance required
• Experience: At least 2-3 years of experience as an analyst in healthcare, data reporting or data analysis required
• Healthcare fraud experience: highly preferred
• Data analysis with SQL proficiency: highly preferred
• Knowledge, Skills, and Abilities: Strong verbal/written communication skills.
• Strong analytical, critical thinking, and organizational skills.
• Comprehensive knowledge of CPT, HCPCS, ICD10-CM diagnosis, and procedure codes.
• Strong aptitude for technology-based solutions.
• Ability to develop, introduce, defend, and gain support for new ideas and approaches.
• Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.

Additional Job Details

• Working Conditions This is a hybrid role with at least one team meeting onsite per month in Somerville, MA
• Working Conditions This is a full-time role with a Monday through Friday schedule, generally 8:30-5:00 PM Eastern Time
• Remote workspace requirements: including privacy and security standards, may be verified in accordance with organizational policy
• Remote Type Hybrid
• Work Location 399 Revolution Drive
• Scheduled Weekly Hours 40
• Employee Type Regular Work Shift Day (United States of America)
• Pay Range $63,648.00 - $92,570.40/Annual
• Grade 6

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth.

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

Combat disease. Hold a hand. Help people. Impact the world. Mass General Brigham is a passionate, welcoming community where minds meet caring hearts. Come be a part of the world’s most powerful force in medicine, where every role is important in changing lives. Are you ready? Our history includes New England hospitals founded over 200 years ago, some of the first and most prestigious hospitals in the world. Built on the legacy of two leading academic medical centers, we’re more than a system—we’re leaders in the practice of medicine. Mass General Brigham is committed to serving the community. We are dedicated to enhancing patient care, teaching and research, and taking a leadership role as an integrated health care system. We recognize that increasing value and continuously improving quality are essential to maintaining excellence.