Sr. Program Integrity Analyst
$155,000–$165,000 year
RemoteUnited States
Job Summary
Analyze Medicaid claims, visit, and EVV datasets to identify patterns indicative of fraud, waste, or abuse in home and community-based care. Translate analytical findings into business requirements for product and engineering teams to build scalable detection logic and dashboards. Present fraud insights to state Medicaid agencies and managed care organizations, advising partners on regulatory reporting obligations and program integrity outcomes. This role sits at the intersection of investigative analysis and product development, ensuring detection tools are clinically sound and directly actionable for customers protecting public funds. The position requires a remote location within EST or CST time zones and involves up to 10% travel. HHAeXchange is the leading technology platform for home and community-based care, connecting patients, providers, and states through a comprehensive ecosystem.
Required Qualifications
- Bachelor's degree
- Minimum of 5 years experience in healthcare fraud detection, program integrity, payment integrity, SIU investigation, or a closely related field
- Substantive knowledge of how fraud, waste, and abuse manifests in healthcare billing data
- Working knowledge of how Medicaid programs operate, including how providers enroll, document services, submit claims, and are reimbursed
- Demonstrated ability to recognize FWA patterns in healthcare claims or billing data and distinguish between fraud, waste, and abuse in context
- Strong analytical thinking and investigative problem-solving skills, including the ability to follow a data thread from anomaly to finding to recommendation
- Ability to communicate complex analytical findings clearly and credibly to both technical and non-technical audiences, including engineers, compliance officers, state regulators, and executive stakeholders
- Comfort working with ambiguous or fragmented data architecture — able to locate and reconcile relevant information across multiple systems and tables without a single, spoon-fed source of truth, and willing to invest the time needed to understand data nuances rather than waiting to be handed a clean dataset
- Willingness to explore and adopt AI tools responsibly to enhance productivity and innovation in your role
- Working familiarity with data tools sufficient to query, explore, and validate analytical outputs independently
- Experience presenting fraud findings to state regulators, managed care compliance teams, or legal and law enforcement partners
- Experience with Python, R, or data visualization / business intelligence tools
Desired Qualifications
- Experience with Medicaid HCBS, personal care services, or home care programs
- Familiarity with electronic visit verification (EVV) data and the EVV mandates under the 21st Century Cures Act
- Exposure to AI or machine learning tools applied to healthcare fraud detection or payment integrity
- Professional certifications such as: Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified in Healthcare Compliance (CHC), or Certified Professional Coder (CPC)
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