SIU Fraud Investigator

Mass General Brigham Health Plan; Somerville (MA); Hybrid; USD 80,000 - 116,000; Full time

Job summary

Mass General Brigham Health Plan is seeking a Data Analyst to create, refine, and perform analytic reporting aimed at identifying potential fraudulent, wasteful, or abusive claim submissions.

The role includes preliminary research of providers or members, using public records, contracts, and social media reviews, and documenting analytical activities in clear memoranda and reports. A hybrid, full-time role based in Assembly Row, Somerville.

Qualifications

• Strong data analysis skills and ability to translate findings into actionable insights.
• Experience conducting fraud, waste, and abuse investigations.
• Competence with public records research and information gathering.
• Ability to document analytical work clearly in reports and memoranda.
• Experience interviewing providers, members, or other parties.
• Excellent written and verbal communication skills.

Responsibilities

• Conduct confidential investigations of suspected fraud, waste & abuse.
• Perform data analysis, public records research, document review, and interviews.
• Review policies, provider manuals, and benefits documents relevant to claims submissions.
• Obtain investigative evidence through documents and interviews.
• Analyze diverse data sources and prepare case summaries and reports.
• Stay up to date with industry trends in fraud, waste & abuse.

Skills

Data analysis

Investigations

Public records research

Documentation

Interviewing

Communication

Education

Bachelor's Degree Related Field of Study

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 role will be responsible for creating, refining, and performing various analytic reporting aimed at identifying potential fraudulent, wasteful, or abusive claim submissions. In addition to performing analytics, the Data Analyst will be required to conduct preliminary research of identified providers or members, including public records, contracts, and social media reviews. The analyst will be accountable for documenting analytical and research activities in concise reports or memoranda.

Essential Functions

• Responsible for conducting confidential investigations of suspected fraud, waste & abuse (FWA) involving medical providers, plan members, or other entities or individuals.
• Investigative activities include, but are not limited to: data analysis, public records research, document review, and interviewing.
• Performs case research to include the review, interpretation, and application of payment policies, medical policies, provider manuals, benefits documents, national or local coverage determinations, and other applicable clinical practice parameters, regulations, or guidance pertaining to the submission of claims to health insurance plans.
• Obtains investigative evidence by requesting medical and administrative documents and by conducting interviews of providers, members, or other associated parties.
• Analyzes and interprets multiple sources of data, including health insurance claims, financial transaction information, contract configurations, and other materials.
• Is an expert report writer with the ability to create timely documentation, including investigative plans, case summaries, and interview reports.
• Stays up to date with industry trends, including those pertaining to prevailing fraud, waste & abuse schemes.

Qualifications

Education

• Bachelor's Degree Related Field of Study required; experience can be considered in lieu of a degree

Experience

• At least 5-7 years of experience conducting fraud, waste, and abuse investigations required

Knowledge, Skills, And Abilities

• Strong, demonstrated track record of the ability to execute on time, on budget, and on scope.
• Strong aptitude for technology-based solutions.
• Excellent leadership skills and leadership track record.
• Ability to translate and communicate complex topics in a variety of forums.
• Excellent interpersonal skills.

Additional Job Details (if Applicable)

Working Conditions

• This is a hybrid role that requires an on-site presence at the office in Assembly Row, Somerville roughly once per month
• 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

$79,560.00 - $115,720.80/Annual

Grade

7

EEO Statement

8925 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.

Mass General Brigham Competency Framework

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.