Fraud Audit & Investigations Specialist
About The Position
The Fraud Audit & Investigations Specialist provides administrative and analytical support to the FWA Analyst and Senior Manager, Program Integrity, in conducting fraud, waste, and abuse (FWA) investigations and supporting audit and regulatory deliverables. Under general direction from the Senior Manager, the specialist assists with intake, documentation, and tracking of moderate-complexity investigations; prepares supporting documentation for regulator-ready case files; and supports the Analyst and Senior Manager on complex, high-risk, or multi-agency matters and regulatory deliverables. The role handles standard and moderate-complexity investigations referred through analytics, hotline reports, health plans, or regulators. It involves contacting providers, consumers, caregivers, agencies, health plans, and other parties; reviewing conduct against program requirements; coordinating with internal teams; and escalating complex, high-risk, or legally sensitive matters. The specialist also organizes case files, maintains assigned RFI tracking information, supports external audits, and collaborates with stakeholders across the Medicaid program-integrity ecosystem. This is an individual-contributor role with no supervisory responsibility currently specified. The position is remote with occasional business travel.
Requirements
- Strong organizational and documentation skills, including the ability to independently assemble accurate, well-organized case files.
- Ability to support multiple investigations or tasks simultaneously under general direction and escalate appropriately when complexity exceeds the role's scope.
- Clear written communication skills and the ability to produce accurate, professional case documentation for review.
- Sound judgment and discretion when handling sensitive or confidential information.
- Comfort conducting outbound phone conversations about sensitive or confidential matters, including delivering difficult information with professionalism and empathy.
- Ability to partner with Analysts, the Senior Manager, and cross-functional stakeholders, including compliance, legal, and operations.
- Two to three years of combined experience across LHCSA, MCO/health plan, and/or state regulatory Medicaid roles.
Nice To Haves
- Bachelor's degree preferred; substantial professional experience may be considered in lieu of a formal degree.
- Prior experience in fraud investigations, program integrity, or compliance auditing.
- Experience preparing or responding to regulatory RFIs, audits, or CAP documentation.
- Experience with consumer-directed care programs, such as CDPAP, strongly preferred.
Responsibilities
- Support the FWA Analyst in standard and moderate-complexity investigations into suspected fraud, waste, and abuse referred from analytics, hotline reports, or health plan and regulator referrals.
- Make routine outbound calls to providers, consumers, caregivers, agencies, health plans, and other involved parties to gather information and conduct case-related interviews, following appropriate discretion and privacy protocols.
- Review provider, consumer, and caregiver conduct against program requirements, including CDPAP attestations, relationship restrictions, and EVV compliance.
- Coordinate with analytics, compliance, legal, account management, and other cross-functional teams to gather and validate information relevant to case resolution.
- Recognize and escalate complex, high-risk, or legally sensitive matters to the Analyst or Senior Manager.
- Assemble and organize case files, referral packages, and supporting documentation to meet regulatory sufficiency standards.
- Identify and flag documentation gaps in assigned casework before formal quality control or external submission.
- Pull and analyze conflict reports to identify possible scheduling overlaps, collaborating with appropriate teams and staff to investigate and resolve discrepancies.
- Run and distribute daily and recurring reports and provide general administrative support to the team.
- Assemble and organize documentation for assigned portions of Requests for Information (RFIs) from MFCUs, OMIG, health plans, and other regulators or auditors.
- Maintain assigned entries in the RFI tracking log, including status updates and deadlines.
- Coordinate with Legal, Compliance, Risk & Assurance, and Operations to gather documentation and data for cases and RFIs.
- Support preparation for external audits and assessment requests as directed.
- Develop and apply working knowledge of LHCSA agency operations, MCO/health plan compliance and SIU functions, and state regulator expectations.
- Support the Analyst and Senior Manager on shared investigations and referral processes with MCO/health plan SIU and compliance counterparts.
- Provide a frontline case-handling perspective when investigative and audit processes are designed or refined.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
