Fraud Audit & Investigations Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct and/or assist in investigations related to suspected fraud, waste, abuse, neglect, and exploitation.

• Interview witnesses, collect and safeguard evidence, and document findings in accordance with investigative standards and chain-of-custody protocols.

• Evaluate the actions of providers, consumers, and caregivers against program requirements, including CDPAP attestations, relationship limitations, and EVV compliance.

• Collaborate with analytics to confirm and create data-driven leads that can be converted into case-ready findings.

• Compile case summaries, findings, and recommendations for referrals.

• Conduct quality-control assessments of case files, referrals, and investigative documentation.

• Review compliance with investigative protocols, standard operating procedures (SOPs), and documentation standards.

• Analyze documentation and operational workflows to identify compliance risks and opportunities for process enhancements.

• Detect and address documentation deficiencies prior to internal sign-off or external submission.

• Assist with Program Integrity audit-readiness evaluations.

• Assemble, organize, and verify the quality of RFI response packages for MFCUs, OMIG, health plans, regulators, and auditors.

• Monitor RFI deliverables, timelines, statuses, ownership, and deadlines.

• Collaborate with Legal, Compliance, Risk & Assurance, and Operations teams to collect necessary documentation and data.

• Support external audits and assessment requests.

• Partner with health plan SIU and compliance teams on investigations and referrals.

• Maintain relationships with regulators, MFCUs, and law enforcement partners.

• Provide insights from frontline and health plan perspectives when developing or refining investigative and audit processes.

⛳️ Requirements

• Proven experience in investigating and/or auditing fraud, waste, and abuse within a Medicaid or healthcare environment.

• Knowledge of LHCSA agency operations, MCO/health plan compliance or SIU functions, and expectations from state or federal regulators.

• Understanding of Medicaid program requirements, including consumer-directed care programs like CDPAP.

• Exceptional organizational and documentation capabilities.

• Ability to handle multiple investigations, audits, and RFIs concurrently under tight deadlines.

• Strong written communication skills for creating clear and defensible case and audit documentation.

• Good judgment and discretion when dealing with sensitive or confidential information.

• Capacity to collaborate effectively with compliance, legal, operations, and external stakeholders.

• Bachelor’s degree preferred; significant professional experience may be accepted in place of a formal degree.

• 5–7 years of combined experience in LHCSA, MCO/health plan, and/or state regulatory Medicaid roles.

• Previous experience in fraud investigations, program integrity, or compliance auditing is required.

• Experience in preparing or responding to regulatory RFIs, audits, or CAP documentation is preferred.

• Familiarity with consumer-directed care programs such as CDPAP is strongly preferred.

• CFE, AHFI, or CCEP certification is preferred.

🏝️ Benefits

• Competitive base salary within the specified compensation range.

• Opportunity for remote work.

• Occasional business travel.

• Commitment to an equal opportunity and inclusive workplace culture.

• Access to company-sponsored training, educational programs, and social and recreational activities.