Program Integrity Analyst/Investigator Associate

In this position, you will be responsible for the prospective and retrospective investigation of suspect claims and assisting in initial development of fraud, waste, abuse and over-payment recovery cases. This includes learning to gather, analyze and interpret data and information to provide meaningful results in developing leads, collaboration with internal resources as well as complying with state and federal requirements for fraud, waste and abuse detection and prevention.

• Analyze referrals/leads and determine what type of research/investigation is needed under close supervision.
• Assess intent and potential for fraudulent activities and/or over-payment recovery opportunities under close supervision.
• Contributes to preparations for facilitating settlement negotiations with providers, attorneys and other responsible parties with direct supervision.
• Assist with investigating cases through personal interview, analysis of claims, medical records and other available data.
• Document case activity and fund allocation and conduct follow-up-actions in a timely manner following documented departmental guidelines.
• Provide appropriate notifications to accounts as well as state and federal entities with moderate supervision.
• Assist in completing well documented and substantiated cases to law enforcement agencies which may include the Federal Bureau of Investigations (FBI), the Office of the Attorney General (OIG) and local police departments.

• 4 or more years experience in health insurance operations, or related field. All relevant experience including work, education, transferable skills, and military experience will be considered.
• 2 years of fraud, waste and abuse investigation/loss prevention experience or 3 years medical/pharmacy claims audit research and analytics or a related experience.
• Strong written and oral communication, analytical, problem resolution and negotiation skills.
• Demonstrated ability to present positive, professional behavior.
• Strong quantitative, problem-solving, and computer skills.
• Proficient use of Microsoft Office: Excel and Word.
• This role requires the ability to travel during the workday and potential overnight travel.
• Required to have and maintain a valid driver's license and auto insurance or access to reliable transportation.
• High school diploma (or equivalency) and legal authorization to work in the U.S.

• Bachelors degree in Health Administration, Health Care Informatics, Business Administration or related fields of study
• Knowledge of health care nomenclature and coding, programs, services, claims and fraud, waste and abuse schemes.

Compensation and Benefits:

Pay Range: $60,000.00 - $67,500.00 - $83,100.00 Annual

Pay is based on several factors which vary based on position, including skills, ability, and knowledge the selected individual is bringing to the specific job.

We offer a comprehensive benefits package which may include:

• Medical, dental, and vision insurance
• Life insurance
• 401k
• Paid Time Off (PTO)
• Volunteer Paid Time Off (VPTO)
• And more

To discover more about what we have to offer, please review our benefits page.

Role Designation

Hybrid

Anchored in Connection

Our hybrid approach is designed to balance flexibility with meaningful in-person connection and collaboration. We come together in the office two days each week - most teams designate at least one anchor day to ensure team interaction. These in-person moments foster relationships, creativity, and alignment. The rest of the week you are empowered to work remote.