[Remote] Senior Analyst - Payment Integrity Analytics

Note: The job is a remote job and is open to candidates in USA. Gainwell Technologies is a company focused on improving health and well-being through advanced technologies. The Senior Analyst - Payment Integrity Analytics plays a critical role in supporting state Medicaid agencies by applying fraud, waste, and abuse analytic models to Medicaid claims data and delivering actionable intelligence for investigations.

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
• Variety of leadership and technical development academies to help build your skills and capabilities
• Work flexibility
• Learning
• Career development

Company Overview