Medicaid Fraud Auditor

This is a fully remote position, open to applicants in Connecticut, +9 more states.

📋 Description

• Conduct research and interpret federal and state Medicaid regulations.

• Create suitable audit procedures.

• Analyze claims alongside supporting documentation.

• Identify and substantiate discrepancies.

• Assess potential overpayments.

• Clearly communicate audit conclusions.

• Execute Medicaid compliance, payment, provider, and focused audits across a variety of provider types, services, and program requirements.

• Independently carry out audits from planning and procedure development to testing, analysis, findings, and finalization.

• Investigate statutes, regulations, Medicaid manuals, provider requirements, policies, and other applicable guidance.

• Formulate audit testing procedures that address identified risks and Medicaid regulations.

• Analyze claims, payment data, medical or service documentation, financial records, provider records, and other relevant information.

• Calculate or verify potential Medicaid overpayments.

• Assess complex situations and utilize professional judgment.

• Generate well-supported audit findings that outline requirements, conditions, evidence, and financial implications.

• Maintain comprehensive and accurate audit workpapers and case files.

• Conduct interviews and gather information from providers, beneficiaries/recipients, and other relevant individuals.

• Compile audit reports, Law Enforcement referral summaries, and other written materials.

• Assist the Lead and Manager as required and mentor new staff.

• Engage in meetings and participate in training sessions.

⛳️ Requirements

• 5 years of experience with a BS/BA; 3 years with an MS/MA; 0 years with a PhD.

• Bachelor’s degree in accounting, finance, business, healthcare administration, public health, health science, law, or a related field, or an equivalent combination of education and relevant professional experience.

• Experience in conducting Medicaid, Medicare, healthcare, compliance, financial, internal, or program integrity audits.

• Proven experience in independently planning, executing, documenting, and finalizing audits or complex reviews.

• Capability to research and interpret laws, regulations, policies, contractual obligations, and other authoritative guidance, applying those requirements to audit findings.

• Experience analyzing healthcare claims, billing records, financial data, medical/service documentation, or other provider records.

• Experience in identifying and documenting noncompliance, improper payments, billing discrepancies, or potential overpayments.

• Excellent written communication skills with the ability to produce professional audit correspondence, findings, reports, and technical documentation.

• Strong analytical, organizational, research, and problem-solving abilities.

• Ability to exercise independent judgment within established policies, procedures, and audit methodologies.

• Capacity to manage multiple assignments, prioritize tasks, meet deadlines, and maintain accurate audit documentation.

• Intermediate to advanced proficiency in Microsoft Excel, Word, and PowerPoint.

• Must be a US Citizen.

• Direct experience in Medicaid audits or Medicaid Program Integrity.

• Experience in researching and applying state-specific Medicaid requirements.

• Experience auditing hospitals, pharmacies, laboratories, physicians, dental providers, behavioral health providers, personal care providers, managed care organizations, or other Medicaid provider types.

• Familiarity with Medicaid provider compliance and billing requirements.

• Experience in identifying Medicaid overpayments.

• Professional certification such as CPA, CIA, CFE, CHC, CPC, or a comparable audit, fraud, healthcare, or compliance credential.

🏝️ Benefits

• Eligibility for overtime, shift differential, and a discretionary bonus in addition to base salary.

• Equal opportunity employer, including individuals with disabilities and protected veterans, or other characteristics protected by law.