Healthcare Data Analyst

Description: Perform in-depth evaluation and analysis of potential fraud cases and requests for information using claims information and other sources of data. Support the development of complex cases that involve high dollar amounts, sensitive issues, or that otherwise meet criteria for referral to law enforcement, recoupment of overpayment, and/or administrative action based on reactive and proactive data analysis.

Accountabilities: Work with local management, investigators, and analysts to provide reactive and proactive case development support and to fulfill law enforcement data requests Communicate effectively with internal and external customers, including federal law enforcement officers Validate data analysis results and analytically identify potential fraud, waste and/or abuse situations in violation of Medicare/Medicaid laws, guidelines, policies, and regulations Support management requests for CMS reporting requirements Utilize data analysis techniques to detect aberrancies in Medicare/Medicaid claims data and proactively seeks out and develops leads and cases received from a variety of sources including CMS and OIG, fraud alerts, and referrals from government and private sources Work with Statisticians and Data Analysts to provide proactive data analysis results with statistically high probabilities of producing case referrals to law enforcement, overpayments, and/or administrative actions Prepare, develop, and participate in provider, beneficiary, law enforcement, or staff training as related to Medicare fraud, waste and/or abuse data analysis.

Qualifications: Bachelor’s degree in statistics or related discipline with preference given to MA or MS recipients, and/or relevant work experience as a data analyst Requires a working knowledge of SAS and/or other applications to perform various types of data analysis 2 years’ experience in data analysis as well as demonstrated knowledge of health care and claims or a combination of education and equivalent work experience Demonstrated experience and knowledge of health care information (health claims data; specifically, Medicare and Medicaid, ICD-9-CM and ICD-10-CM codes, physician specialty codes, pharmaceutical data including NCPDP file formats and codes, provider identifiers, etc.)