Fraud Investigator - Medicaid

Peraton; United States; Remote; USD 50,000 - 90,000; Full time

Job summary

An established industry player is seeking a Fraud Investigator to join their team. This role involves data analysis and investigation to combat fraud, waste, and abuse in Medicare and Medicaid programs. The ideal candidate will possess strong analytical skills and a deep understanding of healthcare regulations. You will work closely with state and federal investigators, documenting findings and making recommendations for action. With opportunities for telework and a collaborative environment, this position is perfect for those looking to make a significant impact in national security and healthcare integrity.

Qualifications

• 5 years of experience with a BS/BA or 3 years with an MS/MA.
• Knowledge of Medicare and Medicaid rules and regulations.

Responsibilities

• Research and assess leads of potential fraud in Medicare and Medicaid.
• Document issues citing regulatory violations.

Skills

Analytical Skills

Research Skills

Interpersonal Skills

Organizational Skills

Communication Skills

Education

Bachelor's Degree

Master's Degree

PhD

Tools

PC Proficiency

Job description

Join to apply for the Fraud Investigator - Medicaid role at Peraton

Peraton is a next-generation national security company that drives missions of consequence spanning the globe and extending to the farthest reaches of the galaxy. As the world's leading mission capability integrator and transformative enterprise IT provider, we deliver trusted, highly differentiated solutions and technologies to protect our nation and allies. Peraton operates at the critical nexus between traditional and nontraditional threats across all domains: land, sea, space, air, and cyberspace. The company serves as a valued partner to essential government agencies and supports every branch of the U.S. armed forces. Each day, our employees do the can't be done by solving the most daunting challenges facing our customers. Visit peraton.com to learn how we're keeping people around the world safe and secure.

Program Overview

Performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse in Medicare and Medicaid programs.

About The Role

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.

What you'll do:

• Research and assess leads of potential fraud, waste, and/or abuse in Medicare and Medicaid.
• Contact beneficiaries, review medical records, and make recommendations for appropriate action, including overpayment calculation or referrals for further review.
• Develop cases involving medical providers for actions such as law enforcement referral, education, or recovery.
• Analyze data, draw conclusions, and determine whether leads warrant further investigation.
• Collaborate with state and federal investigators and other personnel as needed.
• Document issues, citing regulatory violations or schemes to defraud the government.
• Organize files and thoroughly document all investigative steps.
• Handle multiple investigations concurrently, analyze billing patterns, and conduct interviews.
• Attend meetings, training, and conferences; some overnight travel may be required.
• Conduct research on relevant offenses, obtain evidence, and verify violations.
• Prepare investigative reports, correspondence, and apply applicable laws and regulations.
• Maintain confidentiality of health privacy information in compliance with laws.

Telework position available within the contiguous United States.

Qualifications

Basic Qualifications:

• 5 years with BS/BA; 3 years with MS/MA; 0 years with PhD
• Knowledge of Medicare and/or Medicaid rules, regulations, policies, and procedures
• Strong interpersonal, analytical, research, and organizational skills
• Ability to work in a fast-paced environment with limited supervision
• Excellent organizational, scheduling, and communication skills
• Proficiency with PCs
• U.S. Citizenship required

Desirable Qualifications:

• Background in investigations (3+ years preferred)
• Experience reviewing claims, medical records, or developing fraud cases
• Knowledge of healthcare provider investigative practices
• Ability to analyze medical claims and records
• Effective communication skills and handling confidential material
• Ability to interpret laws and regulations and work independently or as part of a team

Essential Functions:

• Testify in court about investigative findings if required
• Research, analyze, and draw conclusions regarding suspected violations
• Organize case files and document all steps thoroughly
• Prepare reports, correspondence, and referral summaries
• Educate providers, law enforcement, and advocacy groups on program safeguards
• Communicate effectively internally and externally
• Handle confidential information appropriately
• Attend meetings, training, conferences; overnight travel may be required