Research Analyst, Prepayment Fraud, Waste and Abuse Lead- - West Sacramento, CA (Hybrid)

Gainwell Technologies LLC•West Sacramento, CA

20d•Hybrid

About The Position

As a Prepayment Fraud, Waste and Abuse Research Analyst at Gainwell, you play a critical role in supporting providers, clients, and internal stakeholders through comprehensive research, issue resolution, communication management, and operational support. Leveraging strong analytical and problem-solving skills, you investigate leads, conducting in-depth investigative research, gathering evidence, validating facts, and documenting findings that help determine whether an investigative lead warrants further action. The role includes lead interrogation, system and program knowledge to develop accurate and timely responses and serve as a trusted resource for prepayment fraud, waste and abuse support. This position requires exceptional written and verbal communication skills, sound judgment, attention to detail, and the ability to work independently while collaborating across multiple functional areas. The ideal candidate demonstrates strong leadership, analytical, communication, and problem-solving skills and serves as a subject matter expert for complex inquiries, escalations, and regulatory requirements.

Requirements

Three or more years of experience in healthcare operations, claims processing, provider support, customer service, business process outsourcing, research, or a related field; Medi-Cal experience preferred.
Demonstrated functional lead experience with the ability to provide direction, coaching, and support within a team-oriented environment.
Strong analytical, problem-solving, organizational, and decision-making skills.
Excellent written, verbal, interpersonal, presentation, and facilitation skills, with the ability to effectively communicate and collaborate with providers, clients, leadership, and cross-functional teams.
Experience assessing business processes, identifying improvement opportunities, and developing practical solutions that increase operational effectiveness and service quality.
Working knowledge of healthcare regulations, provider operations, claims processing, customer support practices, and Microsoft Office applications and business systems used to research, track, and resolve inquiries.

Nice To Haves

Medi-Cal experience preferred.

Responsibilities

Provide functional leadership and day-to-day guidance to the Prepayment Fraud, Waste and Abuse Research Analyst team.
Supporting the analysis, research, and resolution of routine to complex inquiries related to potential fraud, waste and abuse leads, investigation of program policies, business processes, and operational procedures in relation to claiming, utilization of subject matter expertise, independent judgment, and established resources to determine appropriate resolutions or escalations.
Gather supporting documentation, claim history, provider information, policy references, and system data needed for medical consultant review, prioritizing assignments and ensuring timely, accurate, and documented comprehensive research summaries and case documentation for decision-maker review.
Collaborate with cross-functional teams to investigate leads, support program initiatives, facilitate escalations, and ensure consistent application of organizational policies, procedures, and regulatory requirements.
Conduct root cause analysis to determine whether identified anomalies are the result of system defects, provider billing errors, training gaps, policy misunderstandings, or potential fraud, waste or abuse concerns.
Assist with provider education activities when directed.
Create comprehensive research summaries and case documentation for consultant review, and identify reoccurring issues, emerging patterns and opportunities for policy, training or system improvements.