Payment Integrity Analytics, Senior Analyst

Gainwell Technologies LLC•Any city, OH

3d•$69,400 - $99,200•Remote

About The Position

The Payment Integrity Analytics, Senior Analyst plays a critical, client-facing role supporting state Medicaid agencies by applying existing fraud, waste, and abuse (FWA) analytic models to Medicaid claims data and delivering monthly, prequalified FWA lead referrals. This role emphasizes producing clear, defensible, and actionable intelligence that can be readily understood and operationalized by state Office of Inspector General (OIG) staff and other program integrity stakeholders. The analyst serves as a trusted analytical partner to the state, presenting and explaining FWA leads, responding to follow-up questions, and supporting investigations through data analysis, documentation, and, when required, testimony and travel related to fraud investigations. The role also includes translating state feedback, investigative outcomes, and audit results into recommendations for analytic improvements, program integrity controls, and broader Medicaid policy or operational changes.

Requirements

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.

Nice To Haves

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.

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.