Note: The job is a remote job and is open to candidates in USA. Devoted Health is on a mission to dramatically improve the health and well-being of older Americans. The Senior Compliance Analyst in the Special Investigations Unit (SIU) plays a crucial role in detecting potentially fraudulent activities within the health plan by analyzing data, conducting research, and preparing reports to mitigate fraud risk and ensure compliance with regulatory requirements.
Responsibilities
- 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
Skills
- 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
- 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
- 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
- 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
- Ability to present findings and collaborate with cross-functional teams, including Payment Integrity and Compliance
Benefits
- Employer sponsored health, dental and vision plan with low or no premium
- Generous paid time off
- $100 monthly mobile or internet stipend
- Stock options for all employees
- Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
- Parental leave program
- 401K program
- And more....
- *\*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.*
Company Overview
Devoted Health is a healthcare company serving seniors and giving them a health care plan with personal guides and world-class technology. It was founded in 2017, and is headquartered in Waltham, Massachusetts, USA, with a workforce of 1001-5000 employees. Its website is https://devoted.com.