Special Investigations Unit Director jobs in Boston, MA

Special Investigations Fraud Analyst

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.

We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.

Working in the Special Investigation Unit (SIU), the Fraud Analyst will be responsible for creating, refining, and performing various analytic reporting aimed at identifying potential fraudulent, wasteful, or abusive claim submissions. In addition to performing analytics, the Data Analyst will be required to conduct preliminary research of identified providers or members to include public record, contract, and social media review, among others. The analyst will be accountable for documenting analytic and research activities within concise reports or memoranda. These activities will be performed for all lines of business, with a focus on Medicare Advantage product monitoring and reporting requirements.

Principal Duties and Responsibilities:

• Use knowledge of healthcare coding conventions to develop and run reports, analyze data to identify suspicious billing patterns, assess the merits of allegations, and present those findings to leadership.
• Analyze claims data to find suspicious billing patterns and outliers, using knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerabilities.
• Conduct preliminary investigations to assess the merits of allegations through fact-gathering and analyses of data sets.
• Organize data and document preliminary investigative steps with a high level of detail and accuracy to clearly and concisely support investigative inferences, conclusions, and recommendations.
• Demonstrate analytical and problem-solving skills to use and interpret information and facts as well as apply critical techniques to the investigative process.
• Report discoveries of fraud or program abuse to external parties, as required by law, rule, or contract.
• Receive investigative requests from field staff, internal claims associates, and underwriting.
• Hold self and others accountable to meet commitments.
• Ensure diversity, equity, and inclusion are integrated as a guiding principle.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Build strong relationships and infrastructures that designate AllWays Health Partners as a people-first organization.
• Other duties as assigned with or without accommodation.

Qualifications:

• BA/BS or equivalent with at least three (3) years of related investigative, claims, compliance, or analyst experience in healthcare, data reporting, and/or data analysis required.
• Proven analytic experience and skilled at manipulating, analyzing, and evaluating large data sets at various levels of detail. Demonstrated advanced analytic capabilities utilizing MS Excel and Access is required; Proficiency with SAS, SQL, Tableau, R-Python or other analytic tools preferred
• Strong verbal/written communication skills, analytic, critical thinking, and organizational skills, including in-depth knowledge of financial/data analysis, analytic and statistical concepts, techniques, and methods.
• Experience with managed care contracting (ability to interpret hospital/provider contracts), medical payment policy, and reimbursement methodology.
• Comprehensive knowledge of CPT, HCPCS, ICD10-CM diagnosis, and procedure codes to assist in claims data analysis related to policies and recovery identification.
• Knowledge of regulations of Medicare and Medicaid Services along with the Massachusetts State Department of Health
• AHFI, CFE, clinical background, or formal data analyst background preferred.
• Prior experience in health care compliance, regulation, SIU, government agency, or similar position related to data analysis or an insurance-related field beneficial.

Working Conditions:

• Normal office working conditions.
• Remote work arrangement

Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.