Compliance/Fraud Specialist

at Serco in Boise, Idaho, United States

Position Description & Qualifications

Serco is seeking a Compliance/Fraud Specialist to join our talented and fast-paced Advisory Services team, which supports federal programs assisting millions of people seeking government health insurance coverage. This dynamic position on the Compliance team will primarily work on the CMS Eligibility Support (ES) Contract supporting external audits, conducting internal compliance reviews, and developing mitigation strategies to address and triage errors.

Job Summary

The Compliance/Fraud Specialist supports program integrity, compliance monitoring, and fraud risk management activities for the Eligibility Support (ES) program. This role focuses on conducting compliance and fraud-focused reviews, identifying risks and trends, and supporting internal reviews, external audits and CMS directed program integrity efforts. The Compliance/Fraud Specialist works cross-functionally with Quality Assurance (QA), Operations, and Program leadership to define review criteria, analyze consumer records, assess compliance with policies, Standard Operating Procedures (SOPs), and CMS requirements, and escalate potential compliance or fraud risks as appropriate.

This position is part of a cross-cutting program integrity review team and is well suited for candidates with experience in Quality Assurance (QA), Affordable Care Act ( ACA ) Marketplace, Eligibility Support programs, or related compliance and fraud prevention programs.

In this role you will:

+ Conduct compliance, fraud and program integrity reviews to ensure adherence to internal processes, SOPs, Document Verification Guides (DVGs), and CMS requirements

+ Define review criteria and methodologies for compliance and program integrity assessments

+ Pull, analyze, and review records, applications, and supporting documentation to evaluate compliance with eligibility verification and program requirements

+ Identify trends, patterns, anomalies, and potential compliance or fraud-related risks

+ Document review findings clearly and accurately, including root causes and risk impacts

+ Support program integrity and fraud risk management efforts by identifying potential fraud indicators, high-risk submissions, or anomalous activity

+ Participate in risk-based monitoring activities, including enhanced document integrity checks and pattern recognition

+ Assist with escalation of potential program integrity, compliance, or fraud concerns following established processes

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