Experienced Compliance/Fraud Specialist

Position Description & Qualifications Serco is seeking an Experienced 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. 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, SOPs, and CMS requirements, and escalates 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 QA, Affordable Care Act (ACA) Marketplace, Eligibility Support programs, or related compliance and fraud prevention programs. This is a hybrid position (requires 2 days on site at corporate headquarters) in Herndon, VA. In this role, you will: Conduct compliance, fraud and program integrity reviews to ensure adherence to internal processes, SOPs, 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. To be successful in this role, you will have: 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). A minimum of 5 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 DVGs and 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. The ability to travel up to 10% of the time. Additional desired experience and skills: 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. 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 Serco