Fraud & Compliance Specialist - Eligibility Programs

Position Description & Qualifications Serco is seeking a Compliance/Fraud Specialist to join our 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 expedite potential compliance or fraud risks as appropriate. Responsibilities 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. Contribute to recommendations for process improvements, controls, or tools to mitigate identified risks. Assist in assessing risk and impact for identified compliance or integrity issues. Maintain accurate records and documentation to support reporting and follow‑up activities. Support internal compliance reviews and external government audits by gathering requested information and documentation. Assist with responses to external audit findings within required timelines. Collaborate with QA, operations, and leadership teams to align compliance activities with program requirements. Share insights and findings to support continuous improvement of eligibility verification and compliance processes. Requirements U.S. Citizenship. Bachelor’s degree in business, Healthcare Administration, Public Administration, Criminal Justice, Information Systems, or a related field (experience may be substituted in lieu of degree). 3 years experience in compliance, quality assurance, program integrity, fraud identification or eligibility support. Knowledge of ACA Marketplace and/or Eligibility Support (ES) programs. Experience reviewing records, applications, or documentation against defined criteria or requirements, including Document Verification Guides (DVGs) and Standard Operating Procedures (SOPs). Strong analytical skills with the ability to identify patterns, trends, and risks. Strong attention to detail and documentation skills. Ability to interpret policies, procedures, and guidance and apply them consistently. Strong written and verbal communication skills. Ability to travel up to 10%. Preferred Qualifications Prior QA experience within ACA Marketplace or ES programs. Experience supporting audits or compliance reviews. Familiarity with fraud risk indicators or program integrity monitoring. Experience working with CMS‑directed initiatives or government program oversight. Ability to work independently and manage multiple reviews or priorities. Benefits Medical, dental, and vision insurance. Robust vacation and sick leave benefits, and flexible work arrangements where permitted by role or contract. 401(k) plan that includes employer matching funds. Tuition reimbursement program. Life insurance and disability coverage. Optional coverages that can be purchased, including pet insurance, home and auto insurance, additional life and accident insurance, critical illness insurance, group legal, ID theft protection. Birth, adoption, parental leave benefits. Employee Assistance Plan. Pay Transparency Our Total Rewards package includes competitive pay, performance‑based incentives, and benefits that promote well‑being and work‑life balance—so you can thrive both professionally and personally. Eligible employees also gain access to a wide range of benefits from comprehensive health coverage and health savings accounts to retirement plans, life and disability insurance, and time‑off programs that support work‑life balance. Program availability may vary based on factors such as contract type, location, hire date, and applicable collective bargaining agreements. Salary range: The range for this position can be found at the top of this posting. This range is provided as a general guideline and represents a good faith estimate across all experience levels. Actual base salary will be determined by a variety of factors, including but not limited to, the scope of the role, relevant experience, job‑related knowledge, education and training, key skills, and geographic market considerations. For roles available in multiple states, the range may vary to reflect differences in local labor markets. In addition to base salary, eligible positions may include other forms of compensation such as annual bonuses or long‑term incentive opportunities. EEO Statement Serco is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics. #J-18808-Ljbffr