Fraud Audit & Investigations Analyst
About The Position
Public Partnerships LLC supports individuals with disabilities or chronic illnesses and aging adults, to remain in their homes and communities and “self” direct their own long-term home care. Our role as the nation’s largest and most experienced Financial Management Service provider is to assist those eligible Medicaid recipients to choose and pay for their own support workers and services within their state-approved personalized budget. We are appointed by states and managed healthcare organizations to better serve more of their residents and members requiring long-term care and ensure the efficient use of taxpayer funded services. Our culture attracts and rewards people who are results-oriented and strive to exceed customer expectations. We desire motivated candidates who are excited to join our fast-paced, entrepreneurial environment, and who want to make a difference in helping transform the lives of the consumers we serve. The Program Integrity Fraud Audit & Investigations Analyst conducts fraud, waste, and abuse (FWA) investigations and serves as the team's lead for quality control and regulatory deliverable readiness. This role investigates suspected FWA, audits and quality-checks case files and referral packages for completeness and regulatory sufficiency and owns the preparation and packaging of materials in response to Requests for Information (RFIs) from regulators, health plans, and law enforcement. With a broad view of the Medicaid ecosystem, spanning LHCSA/provider agency operations, MCO/health plan processes, and regulator expectations, this person ensures investigations and audit deliverables meet the standards of OMIG, MFCUs, health plan partners, and other oversight bodies.
Requirements
- Demonstrated experience investigating and/or auditing fraud, waste, and abuse in a Medicaid or healthcare setting
- Familiarity with LHCSA agency operations, MCO/health plan compliance or SIU functions, and state or federal regulator expectations; experience across more than one of these perspectives is a strong plus
- Working knowledge of Medicaid program requirements, including consumer-directed care programs (e.g., CDPAP)
- Excellent organizational and documentation skills; comfortable assembling audit-ready, regulator-facing materials
- Ability to manage multiple investigations, audits, and RFIs simultaneously under deadline pressure
- Strong written communication skills; able to produce clear, defensible, and professional case and audit documentation
- Sound judgment and discretion when handling sensitive or confidential information
- Comfortable partnering across compliance, legal, operations, and external stakeholders
Nice To Haves
- Experience preparing or responding to regulatory RFIs, audits, or CAP documentation
- Experience with consumer-directed care programs (e.g., CDPAP) strongly preferred
- CFE, AHFI, or CCEP preferred
Responsibilities
- Conduct and/or support investigations into suspected fraud, waste, abuse, neglect, and exploitation referred from analytics, hotline reports, or health plan/regulator referrals
- Interview witnesses, gather and preserve evidence, and document findings in accordance with investigative standards and chain-of-custody practices
- Assess provider, consumer, and caregiver conduct against program requirements, including CDPAP-specific issues such as attestations, relationship restrictions, and EVV compliance
- Partner with the analytics function to validate and further develop data-driven leads into case-ready findings
- Prepare case summaries, findings, and referral recommendations for the Senior Director and, as applicable, external agencies
- Perform quality control review of case files, referrals, and investigative documentation for completeness, accuracy, and regulatory sufficiency
- Audit adherence to internal investigative protocols, SOPs, and documentation standards
- Analyze documentation and operational processes to assess compliance with established requirements, identify potential risks, and propose solutions for process improvements.
- Identify and remediate documentation gaps prior to internal sign-off or external submission
- Support internal audit-readiness reviews of the Program Integrity function
- Serve as the lead for compiling, organizing, and quality-checking response packages for Requests for Information from MFCUs, OMIG, health plans, and other regulators or auditors
- Ensure RFI responses are complete, accurate, well-organized, and appropriately documented; track deliverables and timelines to support timely submission and resolution.
- Coordinate cross-functionally (Legal, Compliance, Risk & Assurance, Operations) to gather required documentation and data
- Maintain a tracking log of all open and closed RFIs, including status, owners, and deadlines
- Support preparation for external audits and assessment requests in partnership with the Risk and Assurance team
- Serve as a subject matter expert with working knowledge of LHCSA agency operations, MCO/health plan compliance and SIU functions, and state regulator expectations
- Partner with MCO/health plan SIU and compliance counterparts on shared investigations and referral processes
- Support the Senior Director in maintaining relationships with regulators, MFCUs, and law enforcement partners
- Provide the frontline and health plan perspective when designing or refining investigative and audit processes
Benefits
- Base salary within the posted range
- Compensation determined by skills, experience, and geographic location
- Compensation may vary for positions based in high cost-of-labor markets
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
