Medicaid Fraud Auditor

Peraton•,

22h•$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. This position requires an individual who can research and interpret federal and state Medicaid requirements, develop appropriate audit procedures, analyze claims and supporting documentation, identify and substantiate exceptions, determine potential overpayments, and clearly communicate audit conclusions. The role involves conducting Medicaid compliance, payment, provider, and focused audits involving a variety of provider types, services, and Medicaid program requirements. The auditor will independently perform audit activities from planning and development of audit procedures through testing, analysis, findings, and completion of the audit. This is a remote position, and candidates must reside within the Northeast Jurisdiction, which includes Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New York, Pennsylvania, New Jersey, Delaware, Maryland, and the District of Columbia.

Requirements

5 years with BS/BA; 3 years with MS/MA; 0 years with 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 conducting Medicaid, Medicare, healthcare, compliance, financial, internal, or program integrity audits.
Demonstrated experience independently planning, conducting, documenting, and completing audits or complex reviews.
Demonstrated ability to research and interpret laws, regulations, policies, contractual requirements, and other authoritative guidance and apply those requirements to audit findings.
Experience analyzing healthcare claims, billing records, financial information, medical/service documentation, or other provider records.
Experience identifying and documenting noncompliance, improper payments, billing irregularities, or potential overpayments.
Strong written communication skills and demonstrated ability to prepare professional audit correspondence, findings, reports, and other technical documentation.
Strong analytical, organizational, research, and problem-solving skills.
Ability to exercise independent judgment while working within established policies, procedures, and audit methodologies.
Ability to manage multiple assignments, establish priorities, meet deadlines, and maintain accurate audit documentation.
Intermediate to advanced proficiency with Microsoft Excel, Word, and PowerPoint.
Must be a US Citizen.

Nice To Haves

Direct Medicaid audit or Medicaid Program Integrity experience.
Experience 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.
Experience with Medicaid provider compliance and billing requirements.
Experience identifying Medicaid overpayments.
Professional certification such as CPA, CIA, CFE, CHC, CPC, or a comparable audit, fraud, healthcare, or compliance credential.

Responsibilities

Conduct Medicaid compliance, payment, provider, and focused audits involving a variety of provider types, services, and Medicaid program requirements.
Independently perform audit activities from planning and development of audit procedures through testing, analysis, findings, and completion of the audit.
Research and interpret federal and state statutes, regulations, Medicaid manuals, provider requirements, policies, and other applicable guidance.
Develop audit testing procedures that address identified risks and applicable Medicaid requirements.
Analyze Medicaid claims, payment data, medical or service documentation, financial records, provider records, and other information to identify potential noncompliance and improper payments.
Determine, calculate, or validate potential Medicaid overpayments using appropriate audit methodologies and supporting documentation.
Evaluate unique or complex circumstances and exercise professional judgment in determining appropriate audit procedures and conclusions.
Develop well-supported audit findings that clearly identify the applicable requirement, condition, supporting evidence, and financial impact.
Maintain complete, accurate, and well-organized audit workpapers and case files documenting the audit procedures performed, evidence reviewed, analysis conducted, and conclusions reached.
Conduct interviews and obtain information or statements from providers, beneficiaries/recipients, and other relevant individuals when appropriate.
Prepare audit reports, Law Enforcement referral summaries, and other written products.
Support Lead and Manager as needed and mentor new staff.
Actively participate in meetings and attend training to further business acumen.