[Hiring] Sr. Program Integrity Analyst @HHAeXchange

Role Description

The Sr Program Integrity Analyst is a key member of HHAeXchange’s growing Program Integrity function, responsible for identifying fraud, waste, and abuse patterns in Medicaid home and community-based care data and translating those findings into scalable detection capabilities embedded within the HHAeXchange platform. This role sits at the intersection of investigative analysis, product development, and customer engagement.

• Analyze Medicaid claims, visit, and EVV datasets to identify patterns and anomalies indicative of fraud, waste, or abuse in home and community-based care settings.
• Apply knowledge of how FWA manifests in Medicaid billing to identify suspicious patterns, including:
  • Visit overlaps
  • Impossible billing hours
  • Upcoding
  • Duplicate or unbundled claims
  • Provider billing spikes
  • Beneficiary identity issues
  • EVV inconsistencies
• Distinguish between fraud, waste, and abuse, and recommend appropriate investigative or corrective responses for each category.
• Conduct proactive analysis to surface emerging fraud trends and systemic program integrity risks.
• Apply knowledge of the Medicaid revenue cycle to contextualize billing anomalies and assess their program integrity implications.
• Translate analytical findings and fraud patterns into clear, precise business requirements for product and engineering teams.
• Contribute to the design of fraud detection dashboards, alerting systems, and investigation workflows.
• Validate that detection tools and analytical models perform as intended.
• Present fraud findings and program integrity insights to state Medicaid agencies, managed care organizations, and internal stakeholders.
• Support customers in understanding detection findings related to regulatory reporting obligations.
• Advise state and payer partners on how HHAeXchange detection capabilities align with CMS Medicaid Integrity Program standards.
• Document analytical methodologies and investigation approaches to support customer compliance reviews.
• Contribute to customer discussions on detection strategy.
• Other duties as assigned by supervisor or HHAeXchange leader.

Qualifications

• Bachelor’s degree and a 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.
• Demonstrated ability to recognize FWA patterns in healthcare claims or billing data.
• Strong analytical thinking and investigative problem-solving skills.
• Ability to communicate complex analytical findings clearly and credibly.
• Comfort working with ambiguous or fragmented data architecture.
• Demonstrated ability to work as a builder in an evolving environment.
• Working familiarity with data tools sufficient to query, explore, and validate analytical outputs independently.
• Willingness to explore and adopt AI tools responsibly.

Requirements

• 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.
• Experience presenting fraud findings to state regulators, managed care compliance teams, or legal and law enforcement partners.
• 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)
  • Certified Professional Coder (CPC)
• Experience with Python, R, or data visualization / business intelligence tools.

Benefits

• Competitive health plans
• Paid time-off
• Company paid holidays
• 401K retirement program with a Company elected match
• Other company sponsored programs