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 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.
Tavsif
- 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.
Talablar
- 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.
Imtiyozlar
- Remote work arrangement.
- Occasional business travel.
- Equal-opportunity, inclusive workplace.