Fraud Investigator/Auditor

This is a fully remote position, open to applicants in Connecticut, +10 more states.

📋 Description

• Oversee the complete case lifecycle concerning potential fraud, waste, and abuse issues within the Medicaid program integrity.

• Receive, evaluate, and categorize complaints, referrals, and leads.

• Establish jurisdiction, scope, and initial validity of claims.

• Analyze provider data, billing trends, and case documentation.

• Review matters for duplicates, previous reviews, or those outside the scope.

• Coordinate conflict resolution with CMS, state Medicaid agencies, managed care organizations, and partner agencies.

• Record vetting results, case status, contacts, and rationale for disposition.

• Carry out provider audits and investigations, which include claims analysis, medical record examinations, and interviews.

• Detect billing discrepancies, documentation shortcomings, and systemic weaknesses.

• Formulate evidence-based findings for potential administrative, civil, or criminal proceedings.

• Draft, propose, and implement administrative remedies, including overpayment determinations and referrals.

• Compile reports for CMS, state agencies, and law enforcement collaborators.

• Assist in rebuttals, appeals, and settlements relating to administrative findings.

• Keep thorough case documentation in specified tracking systems.

• Ensure adherence to the CMS Program Integrity Manual, Statement of Work, and state-specific regulations.

• Contribute to reports, dashboards, and metrics that track case outcomes, recoveries, and contract performance.

• Organize and analyze complex evidentiary patterns, interview witnesses, and gather statements.

• Investigate relevant offenses, laws, rules, and regulations.

• Prepare unbiased correspondence and investigative reports.

• Safeguard the confidentiality of health privacy information.

⛳️ Requirements

• 5 years of experience with a BS/BA or 3 years with a Master's Degree.

• Exceptional investigative abilities.

• Strong communication and organizational skills.

• Proficient knowledge and skills in PC usage.

• Must be a US Citizen.

• Experience in reviewing claims for technical requirements, conducting medical reviews, and/or developing fraud cases.

• Familiarity with investigative practices related to healthcare providers.

• Understanding of Medicare and/or Medicaid programs along with associated rules, regulations, policies, and procedures.

• Background in evaluating, reviewing, and analyzing medical claims and records.

• Capability to learn and utilize various data systems, equipment, and investigative tools.

• Proficient in conducting research and drawing conclusions.

• Ability to present regulatory violations and alleged schemes or scams aimed at defrauding the Government.

• Competence in organizing case files and accurately documenting investigative procedures.

• Skill in composing correspondence, reports, and summary letters for referrals.

• Ability to communicate effectively both internally and externally.

• Capacity to interpret laws and regulations.

• Proficiency in handling confidential materials.

• Ability to report work activities in a timely manner.

• Capability to work independently as well as collaboratively within a team.

• Willingness to attend meetings, training sessions, and conferences.

• Ability to appear in court and testify regarding investigative findings.

🏝️ Benefits

• Potential eligibility for overtime compensation.

• Shift differentials may be available.

• Discretionary bonuses may be offered.

• Overnight travel required.