SIU Fraud Analyst

massgeneralbrigham; 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 generating regulatory reports. The role focuses on identifying fraudulent, wasteful, or abusive claim submissions while performing research on providers or members.

The ideal candidate has a healthcare fraud background, SQL proficiency, and strong analytical and communication skills.

Qualifications

• Bachelor's Degree is required.

Responsibilities

• Develop and run reports to identify suspicious billing patterns and present findings to leadership.
• Analyze claims data to find suspicious patterns using CPT/HCPCS/ICD10‑CM knowledge.
• Conduct preliminary investigations with data analysis to assess merits of allegations.
• Document investigative steps with detail to support inferences and recommendations.
• Report fraud discoveries to external parties as required by law, rule, or contract.
• Receive investigative requests from field staff, internal claims teams, and underwriting.

Skills

SQL proficiency

Analytical

Communication skills

Healthcare coding knowledge

Education

Bachelor's Degree

Job description

Site: Mass General Brigham Health Plan Holding Company, Inc.

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.

Job Summary

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
• 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.
• Excellent 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 (if applicable)

• Working Conditions: This is a hybrid role with at least one team meeting onsite per month in Somerville, MA
• Schedule: 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 fact.