Medicaid Fraud Auditor

Peraton; Reston (VA); Remote; USD 90,000 - 130,000; Full time

Job summary

SafeGuard Services (SGS), a Peraton subsidiary, seeks a Medicaid Fraud Auditor to join our SGS team of professionals.

This role researches and interprets federal and state Medicaid requirements, develops audit procedures, analyzes claims, identifies overpayments, and communicates audit conclusions clearly. The position is remote and requires residence within the Northeast Jurisdiction. You will mentor junior staff and contribute at meetings to advance the program integrity mission.

Qualifications

• Bachelor's degree in a related field or equivalent experience.
• 5 years with BS/BA; 3 years with MS/MA; 0 years with PhD.
• Experience conducting Medicaid, Medicare, healthcare, compliance, financial, internal, or program integrity audits.
• Ability to independently plan, conduct, document, and complete audits or complex reviews.
• Ability to interpret laws, regulations, policies, and contractual requirements and apply to audit findings.
• Experience analyzing healthcare claims, billing records, or provider records.
• Identify noncompliance, improper payments, or overpayments.
• Strong written communication and audit reporting skills.
• Strong analytical, organizational, research, and problem-solving skills.
• Ability to work independently within policies and audit methodologies.
• Ability to manage multiple assignments and meet deadlines.

Responsibilities

• Conduct Medicaid compliance, payment, provider, and focused audits across provider types.
• Independently perform audit activities from planning to completion.
• Research federal and state statutes, regulations, and Medicaid manuals.
• Develop audit testing procedures addressing identified risks.
• Analyze claims, data, and records to identify noncompliance and improper payments.
• Determine potential Medicaid overpayments using audit methodologies.
• Maintain complete, accurate audit workpapers and case files.
• Conduct interviews and obtain information from providers and beneficiaries.
• Prepare audit reports and related written products.
• Support Lead and Manager; mentor new staff.
• Participate in meetings and training to enhance skills.

Skills

US Citizenship

Auditing

Research & interpret laws

Communication

Project management

Microsoft Excel

Microsoft Word

Microsoft PowerPoint

Education

Bachelor's degree in accounting, finance, business, healthcare administration, public health, health science, law, or related field

Equivalent combination of education and experience

MS/MA degree (preferred for some roles)

Tools

Microsoft Excel

Microsoft Word

PowerPoint

Job description

Required Qualifications:

• 5 years with BS/BA; 3 years with MS/MA; 0 years with PhD
• Bachelor's degree in accounting, finance, business, healthcare administration, public health, health science, law, or a related field, or an equivalent combination of education and relevant professional experience.
• Experience conducting Medicaid, Medicare, healthcare, compliance, financial, internal, or program integrity audits.
• Demonstrated experience independently planning, conducting, documenting, and completing audits or complex reviews.
• Demonstrated ability to research and interpret laws, regulations, policies, contractual requirements, and other authoritative guidance and apply those requirements to audit findings.
• Experience analyzing healthcare claims, billing records, financial information, medical/service documentation, or other provider records.
• Experience identifying and documenting noncompliance, improper payments, billing irregularities, or potential overpayments.
• Strong written communication skills and demonstrated ability to prepare professional audit correspondence, findings, reports, and other technical documentation.
• Strong analytical, organizational, research, and problem-solving skills.
• Ability to exercise independent judgment while working within established policies, procedures, and audit methodologies.
• Ability to manage multiple assignments, establish priorities, meet deadlines, and maintain accurate audit documentation.
• Intermediate to advanced proficiency with Microsoft Excel, Word, and PowerPoint.
• Must be a US Citizen.

Desirable Qualifications

• Direct Medicaid audit or Medicaid Program Integrity experience.
• Experience researching and applying state-specific Medicaid requirements.
• Experience auditing hospitals, pharmacies, laboratories, physicians, dental providers, behavioral health providers, personal care providers, managed care organizations, or other Medicaid provider types.
• Experience with Medicaid provider compliance and billing requirements.
• Experience identifying Medicaid overpayments.
• Professional certification such as CPA, CIA, CFE, CHC, CPC, or a comparable audit, fraud, healthcare, or compliance credential.

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.

We are looking to add a Medicaid Fraud Auditor to our SGS team of talented professionals.

What you'll do:

This position requires an individual who can research and interpret federal and state Medicaid requirements, develop appropriate audit procedures, analyze claims and supporting documentation, identify and substantiate exceptions, determine potential overpayments, and clearly communicate audit conclusions.

• Conduct Medicaid compliance, payment, provider, and focused audits involving a variety of provider types, services, and Medicaid program requirements.
• Independently perform audit activities from planning and development of audit procedures through testing, analysis, findings, and completion of the audit.
• Research and interpret federal and state statutes, regulations, Medicaid manuals, provider requirements, policies, and other applicable guidance.
• Develop audit testing procedures that address identified risks and applicable Medicaid requirements.
• Analyze Medicaid claims, payment data, medical or service documentation, financial records, provider records, and other information to identify potential noncompliance and improper payments.
• Determine, calculate, or validate potential Medicaid overpayments using appropriate audit methodologies and supporting documentation.
• Evaluate unique or complex circumstances and exercise professional judgment in determining appropriate audit procedures and conclusions.
• Develop well-supported audit findings that clearly identify the applicable requirement, condition, supporting evidence, and financial impact.
• Maintain complete, accurate, and well-organized audit workpapers and case files documenting the audit procedures performed, evidence reviewed, analysis conducted, and conclusions reached.
• Conduct interviews and obtain information or statements from providers, beneficiaries/recipients, and other relevant individuals when appropriate.
• Prepare audit reports, Law Enforcement referral summaries, and other written products.
• Support Lead and Manager as needed and mentor new staff.
• Actively participants at meetings and attends training to further his business acumen.
• This is a remote position, candidates must reside within the Northeast Jurisdiction which include the states of Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New York, Pennsylvania, New Jersey, Delaware, Maryland, and the District of Columbia.