Medicaid Fraud Auditor – Team Lead

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

📋 Description

• Manage the entire lifecycle of Medicaid audits from start to finish.

• Organize audits, perform testing and analysis, compile findings, communicate with providers, and prepare final finding reports.

• Provide daily oversight and guidance to auditors conducting Medicaid audits.

• Ensure that audits are well-planned, documented, reviewed, and completed in compliance with federal and state Medicaid regulations and established audit methodologies.

• Offer technical expertise and consultation regarding Medicaid regulations, audit methodologies, regulatory interpretations, claims analysis, documentation, and findings development.

• Review individual workloads during monthly auditor meetings, assist with prioritization, and perform quality control for the team.

• Set priorities and monitor team workloads to ensure resources align with audit requirements and metrics.

• Oversee the quality of WMM/UCM.

• Track the timeliness of audit updates and escalate issues to management when necessary.

• Mentor team members in recognizing previously undetected fraud, waste, or abuse through proactive or reactive research, analysis, and development.

• Serve as a point of contact for the manager.

• Provide education to providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups on program safeguard issues.

• Collaborate with other designated leads for coverage as needed.

⛳️ Requirements

• A minimum of 8 years of experience with a BS/BA; or 12 years with a high school diploma or equivalent.

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

• Proven experience leading staff in identifying and documenting noncompliance, improper payments, billing irregularities, or potential overpayments.

• Excellent written, verbal communication, and organizational skills.

• Strong computer skills and proficiency in Microsoft Office tools.

• Must be a US Citizen.

• Direct experience with Medicaid audits or Medicaid Program Integrity is preferred.

• Familiarity with researching and applying state-specific Medicaid regulations is desirable.

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

• Knowledge of Medicaid provider compliance and billing requirements is beneficial.

• Experience in identifying Medicaid overpayments is desirable.

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

• Ability to conduct research and draw informed conclusions.

• Capability to present concerns, citing regulatory violations, and allege schemes or scams aimed at defrauding the Government.

• Competence in organizing case files and accurately documenting all steps undertaken.

• Skill in composing correspondence, reports, and referral summary letters.

• Ability to educate various stakeholders, including providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups on program safeguard matters.

• Proficiency in effective communication, both internally and externally.

• Ability to interpret laws and regulations.

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

• Ability to juggle multiple assignments, prioritize tasks, meet deadlines, and maintain precise audit documentation.

• Capability to manage confidential information.

• Proficiency in timely reporting of work activities.

• Ability to work autonomously as well as collaboratively within a team.

• Willingness to attend meetings, training sessions, and conferences; overnight travel is required.

• Ability to document quality control results in WMM according to record type.

• Capacity to coordinate coverage with other designated leads when absent from the office.

🏝️ Benefits

• Potential eligibility for overtime.

• Potential eligibility for shift differential.

• Potential eligibility for a discretionary bonus.