Senior Compliance Analyst, Special Investigations Unit

Job Description

A bit about this role: 

The Senior Compliance Analyst in the Special Investigations Unit (SIU) is a key member of the SIU team supporting the detection of potentially fraudulent activities within the health plan. This role involves collecting and analyzing data, conducting research, and preparing reports and organizing case files supporting investigations to identify and prevent healthcare fraud, waste, and abuse. The Senior Analyst plays a crucial role in developing strategies to mitigate fraud risk and ensure compliance with regulatory requirements.

Your Responsibilities and Impact will include:

• Analyze large datasets to identify patterns, trends, and anomalies indicative of fraudulent activity utilizing advanced analytical techniques and tools to support development of investigative leads.

• Collaborate with auditors and investigators to prepare reports and provider education letters.

• Manage quarterly CMS fraud reports and regulatory memos to determine if Devoted has any FWA exposure/ or risk.

• Intaking and triaging referrals related to fraud, waste, and abuse, inclusive of internal and external referrals.

• Develop comprehensive reports summarizing analyses and trends with recommendations for targeted audits and investigations.

• Work closely with internal departments (e.g.,Payment Integrity, Claims, Clinical Escalations) to share findings and coordinate on concept development and FWA scheme targeting criteria.

• Develop educational materials for internal and external stakeholders (e.g., providers, members, employees).

• Conduct quality assurance (QA) review of case documentation,

• Attend and participate in SIU and PI status meetings (weekly, bi-weekly, quarterly, ad-hoc).

• Stay updated on relevant laws, regulations, and industry standards related to healthcare fraud and contribute to compliance efforts.

Required skills and experience:

• Bachelor’s degree in business, healthcare administration, criminal justice, or a related field.

• Minimum of 3 years of experience in healthcare fraud investigation, medical claims analysis, or a related field.

• Proficiency in data analysis tools (e.g.,Excel/Google Sheets) and knowledge of statistical analysis techniques. 

• Strong analytical and problem-solving skills, with the ability to interpret complex data and draw actionable insights.

• Excellent verbal and written communication skills, with the ability to present findings clearly to diverse audiences.

• High level of attention to detail and accuracy in data analysis and reporting.

Desired skills and experience:

• Fraud Investigation Experience:

  • Minimum of 3 plus years in fraud analytics and detection within healthcare, insurance, Medicare Advantage Organization/Managed Care setting, or law enforcement.

  • ​​Experience in a health plan SIU is highly desirable.

• Data Analysis Background::

  • Experience in analyzing healthcare claims data, utilizing statistical tools and software for insights.  (Data Platforms such as Looker, Tableau, Power BI, SQL, or Qlik Sense) 

  • Utilized Generative AI tools to automate routine investigative tasks, reducing manual review times for complex claim histories and surfacing hidden fraud indicators across high-volume data."

• Regulatory Knowledge: 

  • Familiarity with Medicare and Medicaid regulations, as well as industry standards related to fraud detection and prevention.

  • Familiarity with healthcare claims processing and coding is a plus.

• Effective Communication Skills:

  • Ability to present findings and collaborate with cross-functional teams, including Payment Integrity and Compliance. 

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Salary range: $58,000-$90,000 / year

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salar