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Company

Original Job Post

Booz Allen Hamilton · 3 days ago

Healthcare Fraud Policy Research Analyst, Lead

McLean, VA

Full-time

Onsite

Senior Level

$76K/yr - $172K/yr

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Responsibilities

Grow with our compliance and anti-fraud team with the responsibility to perform advanced analyses to ensure the integrity of health insurance programs.

Assist with developing and implementing the program integrity focused engagement and growth strategy.

Leverage client-specific knowledge and networks to lead, plan, grow, and manage progressively larger and more complex programs.

Generate innovative ideas for creative solutions and collaborate with other subject matter experts to ensure specialized topics are appropriately addressed.

Assist the client in efforts to identify and assess exposure or vulnerability to fraud, waste, and abuse in programs, and provide support and assistance to state program integrity functions.

Assess and monitor the impact of policy and payment changes on access to care, beneficiary health outcomes, and program payments, while applying healthcare payer expertise to address payer strategic and operational priorities.

Qualification

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Data AnalysisReport WritingHealthcare Payer AuditsInterviewingMedicare Parts BCDCMS National Coverage DeterminationsMAC Local Coverage DeterminationsMedicare/Medicaid Coverage RulesAnalytic ProjectsCMS Claims DataProgram Integrity PoliciesProvider ScreeningAudit Report ReviewCMSOne PIPECOSFPSUCMNPPESFederal ProcurementProject ManagementAutomation TechniquesHealthcare Fraud InvestigationInsurance Fraud InvestigationFinancial Crimes InvestigationFraud ExaminationHealthcare Compliance

Required

Experience analyzing, interpreting, and writing reports of data findings to identify vulnerabilities for fraud, waste, and abuse in Medicare and Medicaid programs

Experience with healthcare payer audits, investigations, and reviews, including data analysis, interviewing, report writing and editing, and case presentation or briefing

Knowledge of Medicare Parts A, B, C, and D benefits, including pharmacy drug data

Knowledge of Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations and MAC Local Coverage Determinations

Knowledge of Medicare and Medicaid programs, particularly the coverage and payment rules, as well as models, edits, and various analytic projects

Knowledge of CMS claims data, including Medicare, Medicaid, and Marketplace, in the IDR or CCW environment with Fee-for-Service (FFS), Medicare Advantage encounter data, Medicaid data in the Transformed Medicaid Statistical Information System (T-MSIS), or Prescription Drug Event (PDE) data

Knowledge of program integrity policies, plans, and procedures such as the Medicare Program Integrity manual, the Comprehensive Medicaid Integrity Plan, Provider Screening and Enrollment requirements, or the Medicaid Provider Enrollment Compendium (MPEC)

Ability to review provider and contractor audit reports and policy analyses to assist in identifying and monitoring program vulnerabilities and evaluating the impact of initiatives aimed at preventing or recovering improper payments

Bachelor’s degree in Healthcare, Science, Public Health, Policy, or Administration

Preferred

Experience delivering sensitive information and technical content to a wide range of stakeholders, and using a variety of delivery techniques

Experience working with the CMS and Center for Program Integrity

Knowledge of CMS program integrity related systems and resources, such as One PI, the Provider Enrollment, Chain, and Ownership System (PECOS), the Fraud Prevention System (FPS), Unified Case Management (UCM), and the National Plan and Provider Enumeration System (NPPES)

Knowledge of the federal procurement and proposal process, and project management principles

Ability to apply automation techniques to drive insights and efficiency

Ability to work collaboratively and build effective working relationships

Accredited Healthcare Fraud Investigator (AHFI), Health Care Anti-Fraud Associate (HCAFA), Certified Insurance Fraud Investigator (CIFI), Certified Financial Crimes Investigator (CFCI), Certified Fraud Examiner (CFE), or Certified in Healthcare Compliance (CHC) Certifications

Medical Auditing or Clinical Coding Certifications, such as CPC, CEMA, or CPMA

Project Management Professional (PMP) Certification