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

Gainwell Technologies LLC•West Sacramento, CA

21d•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.

Requirements

Three or more years of experience in healthcare operations, claims processing, provider support, customer service, research, or a related field, with Medi-Cal and fraud/waste/abuse experience preferred.
Strong analytical, problem-solving, and organizational skills, with the ability to research complex issues, develop effective solutions, manage multiple priorities, and perform successfully in a fast-paced environment.
Excellent written, verbal, and interpersonal communication skills, including experience collaborating with providers, clients, internal business partners, and cross-functional teams, and the ability to tailor communications to diverse audiences.
Working knowledge of provider operations, claims processing, and customer support practices, along with proficiency in Microsoft Office applications and business systems used to research, track, and resolve inquiries.
Experience working with business processes. Ability to assess clients' business and identify improvement opportunities

Nice To Haves

Medi-Cal and fraud/waste/abuse experience preferred.

Responsibilities

Analyze, research, and resolve 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.