Analyze Medicaid claims, visit, and billing datasets using SQL and other analytical tools.
Identify patterns and anomalies that may indicate fraud, waste, or abuse, including visit overlaps, inflated or duplicate billing, provider billing spikes, inconsistencies in electronic visit verification (EVV) data, unusual service combinations.
Develop and refine detection queries and analytical logic that can be applied across datasets.
Conduct proactive data analysis to identify emerging fraud patterns and potential program integrity risks.
Translate analytical findings into clear requirements for product and engineering teams.
Contribute to the design of fraud detection dashboards, alerting systems, and investigation workflows.
Support the development of automated detection tools and AI-driven fraud identification capabilities.
Test and validate fraud detection tools and analytics models as they are developed.
Present analytical findings and insights to internal stakeholders and payer clients in a clear and actionable format.
Support discussions with states and managed care organizations regarding fraud detection and program integrity.
Document analytical methodologies and investigation approaches to support compliance and regulatory expectations.

Requirements

3–7 years of experience in healthcare analytics, payment integrity, fraud detection, program integrity, forensic data analysis, or a related field.
Strong SQL proficiency, including the ability to independently query and analyze large datasets.
Experience identifying patterns, anomalies, or outliers in large healthcare claims or billing datasets.
Working knowledge of Medicaid or healthcare billing structures.
Strong analytical and investigative problem-solving skills.
Ability to communicate complex analytical findings to both technical and non-technical audiences.
Comfort working in an evolving environment where new capabilities and processes are being developed.
Experience using AI or machine learning tools for anomaly detection, fraud identification, or predictive analytics in healthcare claims data.
Preferred: Experience with a payment integrity organization, healthcare analytics company, or managed care plan.
Experience with Python, R, or advanced analytics tools.
Experience with electronic visit verification (EVV) data.
Professional certifications such as: Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), Certified in Healthcare Compliance (CHC).
Experience with Medicaid home care, personal care services, or HCBS programs.

Benefits

Competitive health plans
Paid time-off
Company paid holidays
401K retirement program with a Company elected match
Other company sponsored programs

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

SQLdata analysisanomaly detectionfraud detectionpredictive analyticsPythonRelectronic visit verification (EVV)analytical logicautomated detection tools

Soft Skills

analytical problem-solvingcommunicationinvestigative skillsadaptabilitytranslating findingscollaborationdocumentation

Certifications

Certified Fraud Examiner (CFE)Accredited Healthcare Fraud Investigator (AHFI)Certified Professional Coder (CPC)Certified in Healthcare Compliance (CHC)