SIU Fraud Analyst
Mass General Brigham
Summary
The Fraud Analyst is building data analytics for MGB Health Plan's 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 submissions. In 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.
Job description
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.
Qualifications
Education: Bachelor's 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.
Requirements
- Bachelor's Degree
- At least 2-3 years of experience investigating claims or compliance
- At least 2-3 years of experience as an analyst in healthcare, data reporting or data analysis
- Healthcare fraud experience highly preferred
- Data analysis with SQL proficiency highly preferred
- 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
Benefits
- Competitive salaries
- Flexible work options
- Career growth opportunities
- Comprehensive benefits package
Company overview
Mass General Brigham is one of the largest integrated healthcare delivery systems in the United States, formed through the merger of Massachusetts General Hospital and Brigham and Women's Hospital. Based in Boston, Massachusetts, this academic medical center system operates multiple hospitals, specialty facilities, and community health centers throughout New England. The organization is renowned for its world-class patient care, cutting-edge medical research, and comprehensive medical education programs. As a teaching affiliate of Harvard Medical School, Mass General Brigham trains the next generation of healthcare professionals while advancing medical science through groundbreaking research initiatives. The system provides a full continuum of healthcare services, from primary care and preventive medicine to complex specialty treatments and emergency services. With a focus on innovation and patient-centered care, Mass General Brigham consistently ranks among the top hospital systems in the nation for clinical excellence and research output.