Job Description
Job Description A bit about this role: The Senior Compliance Analyst in the Special Investigations Unit (SIU) is a key member of the SIU team supporting the detection of potentially fraudulent activities within the health plan. This role involves collecting and analyzing data, conducting research, and preparing reports and organizing case files supporting investigations to identify and prevent healthcare fraud, waste, and abuse. The Senior Analyst plays a crucial role in developing strategies to mitigate fraud risk and ensure compliance with regulatory requirements. Your Responsibilities and Impact will include: Analyze large datasets to identify patterns, trends, and anomalies indicative of fraudulent activity utilizing advanced analytical techniques and tools to support development of investigative leads. Collaborate with auditors and investigators to prepare reports and provider education letters. Manage quarterly CMS fraud reports and regulatory memos to determine if Devoted has any FWA exposure/ or risk. Intaking and triaging referrals related to fraud, waste, and abuse, inclusive of internal and external referrals. Develop comprehensive reports summarizing analyses and trends with recommendations for targeted audits and investigations. Work closely with internal departments (e.g.,Payment Integrity, Claims, Clinical Escalations) to share findings and coordinate on concept development and FWA scheme targeting criteria. Develop educational materials for internal and external stakeholders (e.g., providers, members, employees). Conduct quality assurance (QA) review of case documentation, Attend and participate in SIU and PI status meetings (weekly, bi-weekly, quarterly, ad-hoc). Stay updated on relevant laws, regulations, and industry standards related to healthcare fraud and contribute to compliance efforts. Required skills and experience: Bachelor’s degree in business, healthcare administration, criminal justice, or a related field. Minimum of 3 years of experien
