Fraud Investigator/Auditor

Peraton•,

20h•$66,000 - $106,000•Remote

About The Position

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse. Peraton is looking for an Auditor/Investigator. The qualified individual will be responsible for managing the full case lifecycle of potential fraud, waste, and abuse (FWA) matters under Medicaid program integrity. This includes receiving and triaging new matters through the intake process, performing detailed vetting and deconfliction with partner agencies, conducting investigative and audit work, and preparing administrative actions when warranted. The position requires a strong ability to balance analytical rigor, regulatory knowledge, and interagency collaboration to ensure program integrity and protect taxpayer dollars. This is a remote position, candidates must reside within the NE Jurisdiction which include the states of Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New York, Pennsylvania, New Jersey, Delaware, Maryland, District of Columbia, and Part B claims in the counties of Arlington and Fairfax and the city of Alexandria in Virginia.

Requirements

5 years with BS/BA or 3 years with a Masters Degree.
Strong investigative skills
Strong communication and organization skills
Strong PC knowledge and skills
Must be a US Citizen
Ability to perform research and draw conclusions.
Ability to organize a case file, accurately and thoroughly document all steps taken.
Ability to compose correspondence, reports and referral summary letters.
Ability to communicate effectively, internally and externally
Ability to interpret laws and regulations
Ability to handle confidential material.
Ability to report work activity on a timely basis.
Ability to work independently and as a member of a team to deliver high quality work

Nice To Haves

Strong background in investigations.
Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases.
Knowledge of investigative practices regarding healthcare providers.
Knowledge of Medicare and/or Medicaid programs and the rules, regulations, policies and procedures
Background in evaluating, reviewing and analyzing medical claims and records.
Ability to learn and operate a variety of data systems, equipment and tools used in investigations.
This position may require the incumbent to appear in court to testify about work findings.
Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government.
Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters
Ability to attend meetings, training, and conferences, overnight travel required

Responsibilities

Receive complaints, referrals, and leads from multiple sources including CMS), state agencies, managed care organizations, law enforcement, and the public.
Perform intake assessment to determine jurisdiction, scope, and preliminary validity of the allegations.
Conduct preliminary analysis of provider data, billing patterns, and case documentation to verify accuracy and completeness.
Vet matters by checking for ongoing or prior reviews, ensuring issues are not duplicative or outside contractual scope.
Perform deconfliction with partner agencies (CMS, State Medicaid agencies, Managed Care Organizations, ) to ensure investigative efforts are not duplicative, and to determine lead ownership.
Document vetting outcomes including reference numbers, case status, partner contacts, and rationale for continuation, reassignment, or closure.
Perform in-depth provider audits and investigations, including claims analysis, medical record reviews, and interviews.
Identify billing irregularities, documentation gaps, or systemic vulnerabilities indicating fraud, waste, or abuse.
Develop investigative findings with supporting evidence for potential administrative, civil, or criminal action.
Draft, recommend, and process administrative remedies including payment overpayment determinations, and referrals.
Prepare clear, defensible reports to CMS, state agencies, and/or law enforcement partners in accordance with policy and regulatory requirements.
Support partner agencies with rebuttals, appeals, and settlements related to administrative findings.
Maintain accurate, timely, and comprehensive documentation of case activity in designated tracking systems.
Ensure compliance with CMS Program Integrity Manual (PIM), Statement of Work (SOW), and state-specific regulations.
Contribute to reports, dashboards, and metrics that track case outcomes, recoveries, and performance against contract requirements.
An investigator uses good judgment and may work independently with minimum supervision and direction.
The investigator also may work as part of a team as there may be times when the investigator needs to work with state and/or federal investigators and other personnel.
An investigator handles multiple caseload assignments concurrently; organizes and analyzes complex evidentiary patterns; interviews and obtains statements from witnesses and others.
Investigators may also be required to complete complex investigative reports that apply regulations or rules to the program(s) affected by the behavior being investigated.
There may also be times when the investigator will need to apply federal or state laws.
Investigators are expected to research and understand the relevant offenses being investigated; conduct efficient and effective investigations concerning those alleged offenses and detect or verify suspected violations; obtain information and evidence by observation, record examination, and interview.
Investigators then analyze the results of the investigation to ascertain if the allegations have been corroborated and work with others to determine the appropriate steps that need to be taken to address the issues.
As part of an investigation, the investigator will need to prepare correspondence; be objective and accurate and communicate with others with tact.
There may be times when investigators need to react to unplanned situations, be flexible in planning their activities and adopt effective courses of action.
As investigators will be working with health privacy information, they also must maintain confidentiality and understand all the laws, rules and regulations concerning health privacy.