Public Partnerships | PPL स्वयं-निर्देशित Medicaid दीर्घकालिक देखभाल कार्यक्रमों के लिए वित्तीय प्रबंधन और प्रशासनिक सेवाएँ प्रदान करता है। इसकी सेवाएँ पात्र Medicaid प्रतिभागियों को देखभालकर्ताओं, जिनमें परिवार के सदस्य और मित्र भी शामिल हैं, का चयन, नियुक्ति और प्रबंधन करने में मदद करती हैं। PPL वेतन-प्रबंधन, भुगतान, कर दस्तावेज़ीकरण, अनुपालन और संबंधित कार्यक्रम प्रशासन का सहयोग देता है। कंपनी प्रतिभागियों, देखभालकर्ताओं, राज्य Medicaid एजेंसियों, प्रबंधित देखभाल संगठनों और अन्य कार्यक्रम प्रशासकों के लिए डिजिटल उपकरण और मार्गदर्शन भी प्रदान करती है। इन जिम्मेदारियों के समन्वय में मदद करके PPL स्वयं-निर्देशित देखभाल मॉडलों का समर्थन करता है, जिनका उद्देश्य लोगों के लिए घर पर देखभाल प्राप्त करना आसान बनाना है।
Fraud Audit and Investigations Specialist
Support Medicaid program integrity through fraud investigations, regulatory requests, and audit preparation. Manage case files and coordinate findings with compliance, legal, and operational teams.
विवरण
- Assist with routine and moderately complex fraud, waste, and abuse investigations.
- Interview providers, consumers, caregivers, agencies, health plans, and other relevant parties by phone.
- Assess conduct against program rules, including CDPAP attestations, relationship restrictions, and EVV requirements.
- Gather and verify information with analytics, compliance, legal, and account management teams.
- Escalate complex, high-risk, or legally sensitive cases.
- Prepare case files, referral packages, and supporting records.
- Check documentation for gaps before quality review or external submission.
- Review conflict reports to find scheduling overlaps and resolve inconsistencies.
- Produce and distribute daily and recurring reports.
- Prepare records for regulatory information requests from MFCUs, OMIG, health plans, and other regulators or auditors.
- Track information requests, status changes, and deadlines.
- Coordinate case and request documentation with Legal, Compliance, Risk & Assurance, and Operations.
- Assist with external audits and assessment requests.
- Build knowledge of LHCSA operations, MCO and health plan compliance, SIU functions, and state regulator expectations.
- Work with MCO and health plan SIU and compliance teams on joint investigations and referrals.
- Contribute frontline case-handling feedback to the design and improvement of investigation and audit processes.
आवश्यकताएँ
- A bachelor's degree is preferred; significant professional experience may substitute for a formal degree.
- Two to three years of combined experience in LHCSA, MCO or health plan, and/or state Medicaid regulatory roles.
- Experience in fraud investigations, program integrity, or compliance auditing is preferred.
- Experience preparing or responding to regulatory information requests, audits, or corrective action plans is preferred.
- Experience with consumer-directed care programs such as CDPAP is strongly preferred.
- Strong organization and documentation skills.
- Ability to independently compile accurate, well-organized case files.
- Ability to manage multiple investigations or tasks at once under general direction.
- Ability to escalate matters when their complexity exceeds the role's scope.
- Clear written communication skills.
- Sound judgment and discretion with sensitive or confidential information.
- Comfort with outbound phone conversations concerning sensitive or confidential matters.
- Ability to communicate difficult information with professionalism and empathy.
- Comfort collaborating with Analysts, the Senior Manager, and cross-functional partners in compliance, legal, and operations.
लाभ
- Remote work arrangement.
- Occasional business travel.
- Equal-opportunity, inclusive workplace.