(765) Data Analyst (Healthcare Fraud)

Description

The company is an IT consulting company that delivers technology solutions, with the aim of cutting costs, improving business processes and services to end users, and giving customers a lasting edge.

The company supports the VA Veterans Health Administration Office of Integrity and Compliance in setting up and running the VHA Fraud Rapid Response Center, known as the VA War Room. The War Room uses data analytics, fraud risk assessment and fast administrative action to protect Veterans and taxpayer dollars, in line with Executive Orders 14395 and 14243.

This is Essential Personnel work on the fraud, waste and abuse analytics team. You report to the Analytics and Technology Program Director and the Senior Data Analyst and work in VA's Palantir analytics and workflow platform on VHA claims, enrollment and exclusion data. You build and test business rules that flag potential fraud and overpayments, and you surface anomalies and prioritized leads for OIC review. Work includes support for a Provider 360 view of community care providers, anomaly detection and network analysis to find coordinated billing schemes. The role is advisory and analytical, and all final decisions rest with Government personnel.

Responsibilities

• Write, test and document business rules and algorithm logic tied to FWA schemes.
• Support the criteria for provider risk scoring and case prioritization.
• Support configuration, code and deployment on VA's Palantir platform, including data pipelines and system integration.
• Help merge claims, enrollment and exclusion data into one Provider 360 view.
• Support anomaly detection and network analysis.
• Run the weekly analytics that feed War Room decision packages and the recurring prioritized lead lists.
• Extract, clean and analyze federal healthcare data to identify FWA, and support claim review workpapers.
• Back-test rules, track their precision, and support QA and corrective action plans. The QASP targets a positive predictive value of at least 65% in month one and 70% by Day 60.
• Support federal benchmarking that aligns VHA data analysis with CMS data and methods.
• Build dashboards, visualizations and data for quarterly fraud trend and improper payment reduction reports, risk governance reporting and leadership briefings.
• Document rule specifications, acceptance criteria and analytic methods, and train VA staff to run War Room analytics on their own.

Requirements

• Legally eligible to work in the United States.
• Able to pass a Tier 2 / Moderate Background Investigation (MBI) and obtain a VA PIV card.
• Bachelor's degree in information technology, computer science or a related field such as data science, statistics or health informatics.
• 2-5 years of federal healthcare data analytics experience, such as with Medicare, Medicaid or VHA data, including writing healthcare analytics business rules.
• Strong coding skills in SQL and Python, or PySpark or R.
• Proficiency with analytics platforms, covering data pipelines, transformations and dashboards.
• Working knowledge of healthcare claims data, including claim types, CPT/HCPCS and ICD-10 codes, NPIs, and provider and beneficiary data.
• Able to handle PHI and sensitive information under HIPAA and VA privacy rules, and to complete the required VA TMS trainings.
• Desired: hands-on experience with Palantir Foundry or Gotham.
• Desired: healthcare FWA or payment integrity analytics experience, such as detecting upcoding, unbundling, duplicate billing, impossible days or excluded providers.
• Desired: experience with VA Community Care data, the CMS Integrated Data Repository (IDR), or the OIG LEIE and SAM exclusion lists.
• Desired: anomaly detection, machine learning or network and link analysis experience.
• Desired: rule back-testing and precision measurement experience, including PPV and false-positive analysis.
• Desired: experience with Power BI, Tableau or similar visualization tools.
• Desired: Certified Fraud Examiner (CFE) or a data or analytics certification.

Conditions

Public Trust clearance.

Equal opportunity employer; applicants are considered without regard to protected status.