Fraud Audit & Investigations Specialist

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

📋 Description

• Assist the FWA Analyst in conducting standard and moderately complex investigations related to fraud, waste, and abuse.

• Perform outbound calls and conduct interviews pertaining to cases with providers, consumers, caregivers, agencies, health plans, and other relevant parties.

• Evaluate conduct against program standards, including CDPAP attestations, relationship limitations, and EVV compliance.

• Collaborate with analytics, compliance, legal, and account management teams to collect and verify information.

• Identify and escalate complex, high-risk, or legally sensitive issues.

• Compile and organize case files, referral packages, and supporting documentation.

• Detect documentation deficiencies prior to quality control or external submissions.

• Analyze conflict reports to uncover scheduling conflicts and address discrepancies.

• Generate and disseminate daily and recurring reports.

• Prepare documentation for regulatory Requests for Information from MFCUs, OMIG, health plans, and other regulatory bodies or auditors.

• Keep RFI tracking entries updated, including status updates and deadlines.

• Work in conjunction with Legal, Compliance, Risk & Assurance, and Operations on case and RFI documentation.

• Assist with external audits and assessment requests.

• Acquire a working knowledge of LHCSA operations, MCO/health plan compliance, SIU functions, and expectations from state regulators.

• Facilitate shared investigations and referral processes with MCO/health plan SIU and compliance counterparts.

• Provide frontline insights on case handling when investigative and audit processes are created or refined.

⛳️ Requirements

• A bachelor's degree is preferred; significant professional experience may substitute for formal education.

• 2–3 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 preferred.

• Familiarity with preparing or responding to regulatory RFIs, audits, or CAP documentation is preferred.

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

• Excellent organizational and documentation abilities.

• Capability to independently compile accurate and well-structured case files.

• Ability to manage multiple investigations or tasks concurrently under general supervision.

• Skill in escalating issues appropriately when complexities exceed the role's scope.

• Proficient written communication skills.

• Sound judgment and discretion in handling sensitive or confidential information.

• Comfort in conducting outbound phone conversations regarding sensitive or confidential topics.

• Ability to convey difficult information with professionalism and empathy.

• Willingness to collaborate with Analysts, the Senior Manager, and cross-functional stakeholders, including compliance, legal, and operations.

🏝️ Benefits

• Remote work arrangement.

• Occasional business travel.

• Equal opportunity and inclusive workplace.