Medical/Health Care Program Analyst

About the role

This position supports fraud, waste, and abuse prevention within the Medicaid Program Integrity bureau. It involves conducting investigations, analyzing complex data trends, and developing referrals to law enforcement or regulatory agencies to ensure provider compliance with federal and state laws, policies, and contracts.

Responsibilities

• Perform investigations, audits, and research using investigative tools and data analysis.
• Develop and submit referrals, audit reports, and summaries related to Medicaid providers.
• Identify patterns in data to detect fraudulent or abusive behaviors.
• Conduct pre-payment reviews, site visits, and payment restrictions.
• Collaborate with operational units and participate in special projects.
• Utilize FACTS system for case management, reporting, and user access management.

Requirements

• Successful background screening.
• Legal ability to travel.
• Compliance with drug-free workplace policies.

Qualifications & Skills

Experience in regulatory or health services settings, with knowledge of Medicaid and investigative principles.

Strong problem-solving, research, and investigative skills, with effective communication abilities.

Proficiency in Microsoft Office and research tools.

Ability to work independently and interpret laws, policies, and data trends.

Preferred Qualifications: Certifications such as Certified Fraud Examiner or Healthcare Fraud Investigator, and experience in business or data analysis are advantageous.