Sr. Program Integrity Analyst

Essential Job Duties

Fraud Waste and Abuse Analysis and Fraud Pattern Identification

• Analyze Medicaid claims, visit, and EVV datasets to identify patterns and anomalies indicative of fraud, waste, or abuse in home and community-based care settings.
• Apply knowledge of how FWA manifests in Medicaid billing to identify suspicious patterns, including visit overlaps, impossible billing hours, upcoding, duplicate or unbundled claims, provider billing spikes, beneficiary identity issues, and EVV inconsistencies.
• Distinguish between fraud (intentional misrepresentation), waste (overutilization without intent), and abuse (improper practice), and recommend appropriate investigative or corrective responses for each category.
• Conduct proactive analysis to surface emerging fraud trends and systemic program integrity risks, not solely in response to known or referred patterns.
• Apply knowledge of the Medicaid revenue cycle to contextualize billing anomalies and assess their program integrity implications.

 

Product and Engineering Collaboration

• Translate analytical findings and fraud patterns into clear, precise business requirements for product and engineering teams, specifying what detection logic should catch, what data signals trigger it, and what thresholds or conditions apply.
• Contribute to the design of fraud detection dashboards, alerting systems, and investigation workflows, ensuring that tools are grounded in how investigators and compliance teams actually operate.
• Validate that detection tools and analytical models perform as intended — identifying false positives, coverage gaps, and missed risk categories as they are developed and refined.
• Serve as the subject matter expert on FWA and program integrity concepts, ensuring that detection logic embedded in the platform is operationally sound and clinically credible.

 

Customer and Stakeholder Engagement

• Present fraud findings and program integrity insights to state Medicaid agencies, managed care organizations, and internal stakeholders in formats that are clear, credible, and directly actionable.
• Support customers in understanding what detection findings mean for their regulatory reporting obligations, corrective action priorities, audit readiness, and program integrity outcomes.
• Advise state and payer partners on how HHAeXchange detection capabilities align with CMS Medicaid Integrity Program (MIP) standards and applicable federal program integrity requirements.
• Document analytical methodologies and investigation approaches to support customer compliance reviews, regulatory audits, and reporting obligations.
• Contribute to customer discussions on detection strategy, helping state and MCO partners prioritize program integrity efforts based on risk exposure and data findings.

Other Job Duties

Other duties as assigned by supervisor or HHAeXchange leader.

Travel Requirements

• Travel up to 10%, including overnight travel

Required Education, Experience, Certifications and Skills

• Bachelor’s degree and a minimum of 5 years experience in healthcare fraud detection, program integrity, payment integrity, SIU investigation, or a closely related field, with substantive knowledge of how fraud, waste, and abuse manifests in healthcare billing data.
• Working knowledge of how Medicaid programs operate, including how providers enroll, document services, submit claims, and are reimbursed.
• Demonstrated ability to recognize FWA patterns in healthcare claims or billing data and distinguish between fraud, waste, and abuse in context.
• Strong analytical thinking and investigative problem-solving skills, including the ability to follow a data thread from anomaly to finding to recommendation.
• Ability to communicate complex analytical findings clearly and credibly to both technical and non-technical audiences, including engineers, compliance officers, state regulators, and executive stakeholders.
• Ability to work effectively in an evolving environment where capabilities and processes are actively being developed.
• Working familiarity with data tools sufficient to query, explore, and validate analytical outputs independently.
• Willingness to explore and adopt AI tools responsibly to enhance productivity and innovation in your role.

Preferred

• Experience with Medicaid HCBS, personal care services, or home care programs.
• Familiarity with electronic visit verification (EVV) data and the EVV mandates under the 21st Century Cures Act.
• Experience presenting fraud findings to state regulators, managed care compliance teams, or legal and law enforcement partners.
• Exposure to AI or machine learning tools applied to healthcare fraud detection or payment integrity.
• Professional certifications such as: Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified in Healthcare Compliance (CHC), or Certified Professional Coder (CPC).
• Experience with Python, R, or data visualization / business intelligence tools.