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 preserve evidence, and document findings in accordance with investigative standards and chain-of-custody protocols.

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

• Collaborate with analytics to verify and create data-driven leads that are ready for case development.

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

• Perform quality control reviews of case files, referrals, and investigative documentation.

• Audit compliance with investigative protocols, SOPs, and documentation standards.

• Analyze documentation and operational processes to evaluate compliance, identify risks, and suggest improvements.

• Detect and resolve documentation gaps prior to internal approval or external submission.

• Assist in internal audit-readiness evaluations of the Program Integrity function.

• Compile, organize, and ensure quality of RFI response packages for MFCUs, OMIG, health plans, and other regulatory bodies or auditors.

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

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

• Provide support during external audits and assessment requests.

• Partner with MCO/health plan SIU and compliance teams on joint investigations and referral processes.

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

• Offer frontline and health plan insights while designing or refining investigative and audit procedures.

• Carry out additional duties as assigned.

⛳️ 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.

• Proficient understanding of Medicaid program requirements, including consumer-directed care programs such as CDPAP.

• Exceptional organizational and documentation capabilities.

• Capacity to handle multiple investigations, audits, and RFIs simultaneously while under time constraints.

• Strong written communication skills, with the ability to create clear, defensible, and professional case and audit documentation.

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

• Comfortable collaborating with compliance, legal, operations, and external stakeholders.

• Bachelor's degree preferred; significant professional experience may substitute for formal education.

• 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 essential.

• 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 credentials are preferred but not mandatory.

🏝️ Benefits

• Remote work with occasional business travel.