About this role
Senior data analyst focusing on fraud, waste, and abuse analytics for Medicaid/home care data; builds ML-driven detection capabilities and collaborates with product, engineering, and payer stakeholders.
Key Responsibilities
- Analyze Medicaid claims and EVV data using SQL and analytics tools
- Identify patterns indicating fraud, waste, or abuse
- Develop detection queries and scalable analytics
- Apply ML/AI techniques for anomaly detection and risk scoring
- Translate findings to product/engineering and payer stakeholder guidance
Technical Overview
Deep SQL use with Medicaid claims data, ML/AI techniques for anomaly detection and risk scoring, EVV and HCBS data familiarity, MS Excel/Tableau or similar data visualization, data governance and CMS program integrity awareness.
Ideal Candidate
The ideal candidate is a senior healthcare data analyst with 5–7 years of experience in Medicaid/EVV data, advanced SQL, and ML-based fraud detection, capable of communicating insights to payers and product teams within a remote EST/CST framework.
Must-Have Skills
5–7 years of experience in healthcare analyticspayment integrityfraud detectionprogram integrityforensic data analysisor a related fieldStrong SQL proficiencyExperience identifying patternsanomaliesor outliers in large healthcare claims or billing datasetsSolid understanding of the end-to-end revenue cycleincluding claims submissionadjudicationremittanceand denial/appeal processesWorking knowledge of Medicaid billing structuresincluding HCPCSCPT837P/837Iand applicable billing rules for home and community-based servicesKnowledge of federal Medicaid program integrity regulations (42 CFR Parts 431447and 455) and CMS oversightUnderstanding of how Medicaid MCOs and state Medicaid agencies operateExperience using AI or ML tools for anomaly detectionfraud identificationrisk scoringor predictive analyticsAbility to communicate complex analytical findings to technical and non-technical audiencesComfort with evolving environments and new capabilities
Nice-to-Have Skills
Experience with a payment integrity organizationhealthcare analytics companymanaged care planor state Medicaid agencyPythonRor advanced analytics and data visualization toolsEVV data and EVV mandates under the 21st Century Cures ActMedicaid RAC/UPIC/MIC audit processesML model development and feature engineeringGenerative AI or LLM tools in healthcare analyticsCARC/RARC codes and prior authorization workflowsMedicaid home carePCSor HCBS programsCFE/AHFI/CPC/CHC certifications
Tools & Platforms
SQLPythonREVV data toolsData Visualization tools
Required Skills
5–7 years of experience in healthcare analyticsSQL proficiencyexperience with Medicaid billing structures (HCPCSCPT837P/837I)end-to-end revenue cycle knowledgeEVV data familiarityfamiliarity with CMS program integrity regulationsexperience with ML for anomaly detectionability to communicate findingshealthcare data analyticsdata visualization
Hard Skills
SQLPythonRMachine LearningAnomaly DetectionRisk ScoringUnsupervised ClusteringElectronic Visit Verification (EVV)Medicaid Claims DataHCPCSCPT Codes837P/837IEOB/835CMS program integrityData AnalysisData Visualization
Soft Skills
Analytical thinkingProblem-solvingCommunicationStakeholder engagementPresentationCollaboration
Certifications
Preferred
Certified Fraud Examiner (CFE)Accredited Healthcare Fraud Investigator (AHFI)Certified Professional Coder (CPC)Certified in Healthcare Compliance (CHC)
Keywords for Your Resume
Sr FWA Data AnalystHHAeXchangeMedicaidEVVSQLPythonRMachine LearningFraud detectionProgram integrityCMS program integrity837P/837IHCPCSCPTEOB/835EVV dataMedicaid dataHealthcare analyticsdata visualizationend-to-end revenue cycle
Deal Breakers
Lack of 5–7 years of healthcare analytics experience, No SQL proficiency, Not located in EST or CST time zones (remote requirement)
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