Clinical Fraud Analyst

Clearance Level
None
Category
Business Process Analysis
Location
Pittsburgh, Pennsylvania

REQ#: RQ72540

Travel Required: Less than 10%
Requisition Type: Regular

At GDIT, people are our differentiator. Our work depends on a Clinical Analyst joining our team to support Medicare Program Integrity activities at CMS. As a Clinical Analyst supporting CMS Program Integrity initiatives, you will be trusted to participate in identifying, implementing and maintaining system edits and models to prevent improper payments from the Medicare Trust Fund. You will be part of a 50-person team supporting this important CMS Program Integrity mission.

This GDIT position supports the Program Integrity Modelling and Analytic Services (PIMAS) contract with CMS. PIMAS conducts analysis, data modeling, data mining, and coding to identify and implement edits and models in the CMS Fraud Prevention System (FPS). The Clinical Analyst will be responsible for supporting both edit and model initiatives by identifying risks/vulnerabilities, proposing solutions and assessing performance of existing/proposed solutions.

A typical day as the Clinical Analyst includes regular interactions with staff and leaders in the FPS program, both within GDIT and with other entities working on FPS, including business partners (e.g., system maintainer) and CMS. In addition, the analyst will write and review edit proposals and consult with others regarding policy, medical coding and clinical questions. Receive and reply to CMS urgent requests for information related to edits and other ad hoc program integrity requests. Review CMS policy and regulations to anchor support for new FPS edits and models.

PRIMARY RESPONSIBILITIES

The Clinical Analyst will be responsible for the identification, creation, implementation and maintenance of FPS edits. They will coordinate and effectively communicate with internal and external FPS team members to ensure timely and accurate submission of all edit deliverables.

  • The analyst will identify new candidate topics for possible FPS edits and evaluate them by using data to identify risk and document CMS policy (e.g., LCD, NCD) that supports the edit.
  • The analyst will identify and document gaps or risks in current CMS policy that should be addressed to strengthen Program Integrity initiatives.
  • The analyst will review and assess proposed solutions and provide expert opinion regarding clinical, policy and medical coding aspects of the solution and work with others on the team to determine the best course of action to address known risks/vulnerabilities.

CORE RESPONSIBLITIES

  • Meet all contract requirements for edit deliverables, timeliness and quality
  • Ensure quality in all edit processes, deliverables, and work product
  • Professionally and effectively communicate with staff at all levels
  • Effectively provide clinical, coding and policy input to analysts and programmers with varied experience and expertise

REQUIRED QUALIFICATIONS

  • RN or LPN with 5 years clinical experience
  • 2+ years of experience in Medicare Program Integrity work at a MAC, UPIC or other program integrity contractor
  • 2+ years of experience in clinical coding with the corresponding appropriate professional certification(s) (e.g., CPC) or ability to attain certification within 12 months
  • Technical understanding of Medicare policy, processes and claims payment systems
  • Ability to pass CMS security clearance & background check

DESIRED QUALIFICATIONS

  • 3 years of experience interacting with and consulting with others with a different background/expertise in a team environment
  • BA/BS/BSN
  • 2+ years of experience working with Medicare Fee-for-Service pre-payment edits either in FPS, FISS, MCS, and/or VMS
  • Experience with Medicaid, Medicare Part C/D

WHAT GDIT CAN OFFER YOU

  • Ability to work remotely from anywhere in the US
  • Direct & regular interaction with CMS
  • Be on the front line of stopping fraud, waste and abuse in Medicare
  • Opportunity to work independently but also be part of a passionate team committed to protecting the Medicare Trust Fund
  • Excellent salary and benefits package

GDIT CAREERS

Opportunity Owned

Discover more at www.gdit.com/careers  

We are GDIT. The people supporting some of the most complex government, defense, and intelligence projects across the country. We deliver. Bringing the expertise needed to understand and advance critical missions. We transform. Shifting the ways clients invest in, integrate, and innovate technology solutions. We ensure today is safe and tomorrow is smarter. We are there. On the ground, beside our clients, in the lab, and everywhere in between. Offering the technology transformations, strategy, and mission services needed to get the job done.

GDIT is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status, or any other protected class.