欺诈审计及调查专家

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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. (learn more at www.pplfirst.com).
Job Summary

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 contributes to the team's audit and regulatory deliverable work. Operating under general direction from the Senior Manager, this role assists with intake, documentation, and tracking of moderate-complexity investigations, helps prepare and organize supporting documentation for regulator-ready case files, and provides support to the Analyst and Senior Manager on more complex, high-risk, or multi-agency matters and on regulatory deliverables.

Key Responsibilities

Investigations

• Support the FWA analyst to conduct standard and moderate-complexity investigations into suspected fraud, waste, and abuse referred from analytics, hotline reports, or health plan/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, discussing sensitive and confidential matters and following appropriate discretion and privacy protocols before sharing case-specific details

• Review provider, consumer, and caregiver conduct against program requirements, including CDPAP-specific issues such as attestations, relationship restrictions, and EVV compliance

• Coordinate with cross-functional teams, including analytics, compliance, legal, and account management staff to gather and validate information that drives case resolution.

• Recognize and escalate complex, high-risk, or legally sensitive matters to the Analyst or Senior Manager.

Documentation, Quality and Team Support

• Assemble and organize case files, referral packages, and supporting documentation for assigned cases to meet regulatory sufficiency standards

• Help identify and flag documentation gaps in assigned casework prior to formal quality control or external submission

• Pull and analyze conflict reports to identify possible scheduling overlaps and collaborate with other teams and appropriate staff to investigate and resolve discrepancies as necessary.

• Run and distribute daily and recurring reports, and provide general administrative support to the team as needed
• RFI & Regulatory Deliverable Management

• Assemble and organize documentation for assigned portions of Requests for Information (RFIs) from MFCUs, OMIG, health plans, and other regulators or auditors, under the direction of the Analyst or Senior Manager

• Maintain assigned entries in the RFI tracking log, including status updates and documentation of deadlines

• Coordinate with Legal, Compliance, Risk & Assurance, and Operations to gather documentation and data needed for assigned cases and RFIs

• Support preparation for external audits and assessment requests as directed

Stakeholder & Ecosystem Partnership
• 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 the frontline case-handling perspective when the team is designing or refining investigative and audit processes
Requirements:

• Strong organizational and documentation skills; able to independently assemble accurate, well-organized case files

• Ability to support multiple investigations or tasks simultaneously under general direction, escalating appropriately when complexity exceeds the role's scope

• Clear written communication skills; able to produce accurate, professional case documentation for review

• Sound judgment and discretion when handling sensitive or confidential information

• Comfortable conducting outbound phone conversations with providers, consumers, caregivers, agencies, and health plans on sensitive or confidential matters, including delivering difficult information with professionalism and empathy

• Comfortable partnering with Analysts, the Senior Manager, and cross-functional stakeholders including compliance, legal, and operations

Qualifications:
Education: Bachelor's degree preferred; substantial professional experience may be considered in lieu of a formal degree.

Experience:
· 2-3 years of combined experience across LHCSA, MCO/health plan, and/or state regulatory Medicaid roles
· Prior experience in fraud investigations, program integrity, or compliance auditing preferred
· Experience preparing or responding to regulatory RFIs, audits, or CAP documentation preferred
· Experience with consumer-directed care programs (e.g., CDPAP) strongly preferred

Working Conditions
Remote with occasional business travel.
Supervisory Responsibility (if applicable):
None (individual contributor); TBD as team scales.
Compensation: $63,000 - $83,000
This role is eligible for a base salary within the posted range. Actual compensation will be determined based on a variety of factors, including skills, experience, and geographic location. Compensation may vary for positions based in high cost-of-labor markets.
The above is intended to describe the general contents and requirements of work being performed by people assigned to this classification. It is not intended to be construed as an exhaustive statement of all duties, responsibilities, or skills of personnel so classified

PPL is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PPL, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PPL will not tolerate discrimination or harassment based on any of these characteristics.
If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!
Originally posted on Himalayas