Note: The job is a remote job and is open to candidates in USA. Gainwell Technologies is a company focused on improving healthcare through advanced technologies. They are seeking a Senior Analyst in Payment Integrity Analytics to support state Medicaid agencies by applying analytic models to Medicaid claims data and delivering actionable intelligence on fraud, waste, and abuse.
Responsibilities
- Apply established FWA analytic models to Medicaid claims data to identify potential fraud, waste, and abuse
- Deliver monthly, prequalified FWA lead referral reports on a consistent and reliable cadence
- Produce reports that clearly articulate the analytic rationale, suspected behavior, and investigative relevance of each lead
- Ensure all outputs are defensible, audit-ready, and written for non-technical investigative and policy audiences
- Present FWA lead referrals to state Medicaid program integrity and OIG staff
- Explain findings, methodologies, and data sources in support of state investigations
- Respond to follow-up questions and perform supplemental or ad hoc analyses related to specific referrals
- Support investigations through documentation, exhibits, and data interpretation
- Participate in meetings, briefings, and, as needed, provide testimony or in-person investigative support (travel may be required)
- Provide structured feedback to analytics and data science teams on model performance and data quality
- Recommend enhancements, modifications, or corrections to existing analytic models
- Translate state feedback and investigative outcomes into prioritized analytics roadmap items
- Analyze outcomes of other audit programs to identify systemic program integrity vulnerabilities
- Develop data-driven recommendations related to claims adjudication processes, controls, or edits
- Advise states on potential policy, regulatory, or statutory changes to reduce FWA risk and close program gaps
Skills
- Extensive experience analyzing Medicaid claims and encounter data to identify fraud, waste, and abuse. (5+ years)
- Deep knowledge of Medicaid program integrity, including common FWA schemes, audit methodologies, and investigative workflows. (5+ years)
- Prepare reports and presentations documenting analytic methods and results for internal and external customers (4+ years)
- Experience reading, interpreting, and applying Medicaid policy, regulations, state plan language, and related guidance
- Strong written and verbal communication skills, with experience presenting analytic findings to state agencies, Offices of Inspector General, or other oversight bodies
- Prior experience working directly with state Medicaid agencies and/or Offices of Inspector General is strongly preferred
- Professional certifications such as Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), and/or Accredited Health Care Fraud Investigator (AHFI) are preferred
Benefits
- Generous, flexible vacation policy
- Educational assistance
- Comprehensive health benefits
- 401(k) employer match
- A variety of leadership and technical development academies to help build your skills and capabilities
- Work flexibility
- Learning
- Career development
Company Overview
Company H1B Sponsorship