Payment Integrity Investigator, Senior Analyst

Gainwell Technologies LLC

3d•$64,500 - $92,200•Remote

About The Position

Be part of a team that unleashes the power of leading-edge technologies to help improve the health and well-being of those most vulnerable in our country and communities. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work flexibility, learning, and career development. You’ll add to your technical credentials and certifications while enjoying a generous, flexible vacation policy and educational assistance. We also have comprehensive leadership and technical development academies to help build your skills and capabilities.Job Summary We are seeking an experienced healthcare fraud, waste, and abuse (FWA) investigator and certified coder to support our Program Integrity Audit Unit. The Payment Integrity Investigator, Senior Analyst role conducts professional audits and investigations of Medicaid claims, identifies overpayments and potential fraud, and prepares clear, defensible audit findings for clients. The ideal candidate has strong investigative skills, excellent written documentation abilities, and confidence communicating audit results directly with clients and providers. Your role in our mission · Conduct FWA audits and investigations, including medical record review, coding validation, and claims analysis. · Prepare high‑quality written audit findings, referrals, and overpayment recommendations with clear, defensible rationale. · Communicate audit results to clients professionally and confidently. · Review claims, billing practices, and medical documentation to identify improper payments, aberrant patterns, and potential fraud schemes. · Support referrals to state agencies, OIG, MFCU, or law enforcement and assist in testimony preparation as needed. · Research applicable billing, coding, and reimbursement rules to ensure findings align with Medicaid policy. · Manage a caseload independently, ensuring accuracy, timeliness, and contractual SLA compliance. · Provide subject‑matter guidance to internal teams regarding FWA trends, audit standards, and industry best practices.

Requirements

5+ years of Healthcare FWA Audit or Investigative experience required
Certified coder (CPC, CPMA, or equivalent) with strong knowledge of ICD‑10‑CM, CPT/HCPCS, and Medicaid Reimbursement Methodologies.
Experience analyzing claims, documentation, and billing patterns to determine compliance with program rules.
Strong analytical and critical‑thinking skills; ability to synthesize information from multiple sources.

Nice To Haves

Professional credentials such as CFE, AHFI, or nursing licensure (RN/LPN) preferred.

Responsibilities

Conduct FWA audits and investigations, including medical record review, coding validation, and claims analysis.
Prepare high‑quality written audit findings, referrals, and overpayment recommendations with clear, defensible rationale.
Communicate audit results to clients professionally and confidently.
Review claims, billing practices, and medical documentation to identify improper payments, aberrant patterns, and potential fraud schemes.
Support referrals to state agencies, OIG, MFCU, or law enforcement and assist in testimony preparation as needed.
Research applicable billing, coding, and reimbursement rules to ensure findings align with Medicaid policy.
Manage a caseload independently, ensuring accuracy, timeliness, and contractual SLA compliance.
Provide subject‑matter guidance to internal teams regarding FWA trends, audit standards, and industry best practices.