SIU Fraud Analyst

Site: Mass General Brigham Health Plan Holding Company Inc.

Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a not-for-profit we support patient care research teaching and community service striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

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 worlds 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 welcoming and supportive environment that embraces their unique and varied backgrounds experiences and skills.

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

The Fraud Analyst is building data analytics for MGB Health Plans Special Investigations Unit; this role uses data analytics for the SIU to find fraud leads. This includes creating SQL queries for known fraud schemes to run against claims data ad hoc regulatory reporting and creating reports to support Fraud Investigators.

The ideal candidate is proficient in SQL and has a background in healthcare fraud investigations.

The role will be responsible for creating refining and performing various analytic reports aimed at identifying potential fraudulent wasteful or abusive claim addition to performing analytics the position will be required to conduct preliminary research of identified providers or members to include public records contracts and social media review among others. The analyst will be accountable for documenting analytic and research activities within concise reports or memoranda.

Essential Functions
-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.
-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.

Education

• Bachelors Degree

Experience

• At least 2-3 years of experience investigating claims or compliance required
• At least 2-3 years of experience as an analyst in healthcare data reporting or data analysis required
• Healthcare fraud experience highly preferred
• Data analysis with SQL proficiency highly preferred

Knowledge Skills and Abilities

• Strong verbal/written communication skills.
• Excellent analytical critical thinking and organizational skills.
• Comprehensive knowledge of CPT HCPCS ICD10-CM diagnosis and procedure codes.
• Strong aptitude for technology-based solutions.
• Ability to develop introduce defend and gain support for new ideas and approaches.
• Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.

Working Conditions

• This is a hybrid role with at least one team meeting onsite per month in Somerville MA
• This is a full-time role with a Monday through Friday schedule generally 8:30-5:00 PM Eastern Time
• Remote workspace requirements including privacy and security standards may be verified in accordance with organizational policy

Hybrid

399 Revolution Drive

40

Regular

Day (United States of America)

Pay Range

$63648.00 - $92570.40/Annual

Grade

6

At Mass General Brigham we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive and any offer extended will take into account your skills relevant experience if applicable education certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however it does not encompass all elements contributing to your total compensation addition to competitive base pay we offer comprehensive benefits career advancement opportunities differentials premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

8925 Mass General Brigham Health Plan Holding Company Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973 the Vietnam Veterans Readjustment Act of 1974 and Title I of the Americans with Disabilities Act of 1990 applicants who require accommodation in the job application process may contact Human Resources at .