Medicaid/Medicare Program Integrity Analyst II

Performs evaluation and development of leads, complaints, and/or investigations to verify allegations of potential fraud. Recommends and/or implements appropriate administrative actions. Conducts independent reviews resulting from the discovery of situations that potentially involve fraud or abuse. Utilizes basic data analysis techniques to detect aberrancies in Medicare and Medicaid claims data, and proactively seeks out and develops leads/investigations received from a variety of sources. Reviews information contained in standard claims processing system files to determine provider billing patterns and to detect potential fraudulent or abusive billing practices. Makes potential fraud determinations by utilizing a variety of sources. Compiles and maintains documentation and information related to investigations, cases, and/or leads. Develops and prepares potential Fraud Alerts and program vulnerabilities for submission to CMS. Prepares and submits external correspondence and reports, including, but not limited to, overpayment letters, fraud case referrals, suspensions, rebuttals, Medicare/Medicaid findings reports, and administrative action recommendations.