Public Partnerships | PPL o‘zini o‘zi boshqaradigan Medicaid uzoq muddatli parvarish dasturlari uchun moliyaviy boshqaruv va ma’muriy xizmatlarni taqdim etadi. Uning xizmatlari Medicaid talablariga javob beradigan ishtirokchilarga oila a’zolari va do‘stlarini ham qo‘shgan holda parvarish qiluvchilarni tanlash, ishga olish va boshqarishda yordam beradi, PPL esa ish haqi hisob-kitobi, to‘lovlar, soliq hujjatlari, muvofiqlik va dastur ma’muriyati bilan bog‘liq boshqa jarayonlarni qo‘llab-quvvatlaydi. Shuningdek, kompaniya ishtirokchilar, parvarish qiluvchilar, shtat Medicaid agentliklari, boshqariladigan parvarish tashkilotlari va boshqa dastur ma’murlari uchun raqamli vositalar hamda yo‘l-yo‘riqlarni taqdim etadi. Ushbu mas’uliyatlarni muvofiqlashtirishga yordam berish orqali PPL odamlarga uy sharoitida parvarish olishni osonlashtirishga qaratilgan o‘zini o‘zi boshqaradigan parvarish modellarini qo‘llab-quvvatlaydi.
Fraud Audit and Investigations Analyst - Medicaid Program Integrity (Remote)
Investigate potential fraud, waste, abuse, neglect, and exploitation while auditing Medicaid program integrity and regulatory deliverables. Support case development, compliance reviews, RFIs, audits, and investigative partnerships for Public Partnerships | PPL.
Tavsif
- Investigate suspected fraud, waste, abuse, neglect, and exploitation.
- Interview witnesses, preserve evidence, and document findings in line with investigative and chain-of-custody standards.
- Evaluate provider, consumer, and caregiver conduct against program rules, including CDPAP attestations, relationship restrictions, and EVV requirements.
- Work with analytics teams to validate leads and develop case-ready findings.
- Draft case summaries, investigative findings, and referral recommendations.
- Conduct quality-control reviews of case files, referrals, and investigative records.
- Review compliance with investigative protocols, SOPs, and documentation standards.
- Assess documentation and operational processes for compliance risks and improvement opportunities.
- Resolve documentation deficiencies before internal approval or external submission.
- Assist with audit-readiness reviews for the Program Integrity function.
- Assemble and quality-check RFI response packages for MFCUs, OMIG, health plans, regulators, and auditors.
- Monitor RFI deliverables, deadlines, ownership, and status.
- Coordinate with Legal, Compliance, Risk & Assurance, and Operations to collect required data and records.
- Assist with external audits and assessment requests.
- Collaborate with MCO and health plan SIU and compliance teams on joint investigations and referrals.
- Support working relationships with regulators, MFCUs, and law enforcement partners.
- Apply frontline and health plan perspectives to the design and improvement of investigative and audit processes.
- Complete other assigned duties.
Talablar
- Experience investigating or auditing fraud, waste, and abuse in Medicaid or healthcare environments.
- Understanding of LHCSA operations, MCO or health plan compliance and SIU functions, and state or federal regulatory expectations.
- Working knowledge of Medicaid requirements, including consumer-directed programs such as CDPAP.
- Highly organized, with strong documentation practices.
- Ability to manage multiple investigations, audits, and RFIs under deadline pressure.
- Strong writing skills with the ability to produce clear, defensible case and audit records.
- Sound judgment and discretion when handling sensitive or confidential information.
- Ability to collaborate with compliance, legal, operations, and external stakeholders.
- Bachelor's degree preferred; substantial professional experience may substitute for a formal degree.
- Five to seven years of combined experience in LHCSA, MCO or health plan, and/or state Medicaid regulatory roles.
- Professional experience in fraud investigations, program integrity, or compliance auditing required.
- Experience preparing or responding to regulatory RFIs, audits, or CAP documentation preferred.
- Experience with consumer-directed programs such as CDPAP strongly preferred.
- CFE, AHFI, or CCEP certification preferred but not required.
Imtiyozlar
- Remote position with occasional business travel.