Senior Compliance Analyst, Special Investigations Unit

• 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.

Requirements

• Bachelor’s degree in business, healthcare administration, criminal justice, or a related field.
• Minimum of 3 years of experience in healthcare fraud investigation, medical claims analysis, or a related field.
• Proficiency in data analysis tools (e.g., Excel/Google Sheets) and knowledge of statistical analysis techniques.
• Strong analytical and problem-solving skills, with the ability to interpret complex data and draw actionable insights.
• Excellent verbal and written communication skills, with the ability to present findings clearly to diverse audiences.
• High level of attention to detail and accuracy in data analysis and reporting.