Healthcare Fraud Policy Research Analyst, Lead

Healthcare Fraud Policy Research Analyst, Lead

Key Role:

Grow with our compliance and anti-fraud team with the responsibility to perform advanced analyses to ensure the integrity of Medicare and Medicaid Programs. Assist with developing and implementing the program integrity focused engagement and growth strategy. Leverage client-specific knowledge and networks to lead, plan, grow, and manage progressively larger and more complex programs. Generate innovative ideas for creative solutions and collaborate with other subject matter experts to ensure specialized topics are appropriately addressed. Assist the client in efforts to identify and assess exposure or vulnerability to fraud, waste, and abuse in Centers for Medicare and Medicaid Services (CMS) programs, and provide support and assistance to state program integrity functions. Assess and monitor the impact of policy and payment changes on access to care, beneficiary health outcomes, and CMS program payments, while applying healthcare payer expertise to address payer strategic and operational priorities. Due to the nature of work performed within this facility, U.S. citizenship is required.

Basic Qualifications:

• Experience analyzing, interpreting, and writing reports of data findings to identify vulnerabilities for fraud, waste, and abuse in Medicare and Medicaid programs
• Experience with healthcare payer audits, investigations, and reviews, including data analysis, interviewing, report writing and editing, and case presentation or briefing
• Knowledge of Medicare Parts A, B, C, and D benefits, including pharmacy drug data
• Knowledge of CMS National Coverage Determinations and MAC Local Coverage Determinations
• Knowledge of Medicare and Medicaid programs, particularly the coverage and payment rules, as well as models, edits, and various analytic projects
• Knowledge of CMS claims data, including Medicare, Medicaid, and Marketplace, in the IDR or CCW environment with Fee-for-Service (FFS), Medicare Advantage encounter data, Medicaid data in the Transformed Medicaid Statistical Information System (T-MSIS), or Prescription Drug Event (PDE) data
• Knowledge of program integrity policies, plans, and procedures such as the Medicare Program Integrity manual, the Comprehensive Medicaid Integrity Plan, Provider Screening and Enrollment requirements, or the Medicaid Provider Enrollment Compendium (MPEC)
• Ability to review provider and contractor audit reports and policy analyses to assist in identifying and monitoring program vulnerabilities and evaluating the impact of initiatives aimed at preventing or recovering improper payments
• Bachelor’s degree in Healthcare, Science, Public Health, Policy, or Administration

Additional Qualifications:

• Experience delivering sensitive information and technical content to a wide range of stakeholders, and using a variety of delivery techniques
• Experience working with the CMS and Center for Program Integrity
• Knowledge of CMS program integrity related systems and resources such as One PI, the Provider Enrollment, Chain, and Ownership System (PECOS), the Fraud Prevention System (FPS), Unified Case Management (UCM), and the National Plan and Provider Enumeration System (NPPES)
• Knowledge of the federal procurement and proposal process, and project management principles
• Ability to apply automation techniques to drive insights and efficiency
• Ability to work collaboratively and build effective working relationships
• Accredited Healthcare Fraud Investigator (AHFI), Health Care Anti-Fraud Associate (HCAFA), Certified Insurance Fraud Investigator (CIFI), Certified Financial Crimes Investigator (CFCI), Certified Fraud Examiner (CFE), or Certified in Healthcare Compliance (CHC) Certifications
• Medical Auditing or Clinical Coding Certifications such as CPC, CEMA, or CPMA
• Project Management Professional (PMP) Certification

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