Medicaid Fraud Auditor

Peraton; Reston (VA); Remote; USD 66,000 - 106,000; Full time

Job summary

Peraton's SafeGuard Services seeks a Medicaid Fraud Auditor to join our team. You will research federal/state Medicaid requirements, develop audit procedures, analyze claims, identify potential overpayments, and clearly communicate audit conclusions.

The role emphasizes independent judgment, meticulous documentation, data analysis, and professional reporting. This is a remote position; candidates must reside within the Northeast jurisdiction.

Qualifications

• Bachelor's degree in accounting, finance, business, healthcare administration, public health, health science, law, or related field.
• Experience conducting Medicaid, Medicare, healthcare, compliance, financial, internal, or program integrity audits.
• Ability to plan, conduct, document, and complete audits or complex reviews independently.
• Ability to research and interpret laws, regulations, policies, and apply to audit findings.
• Strong written communication and documentation skills.

Responsibilities

• Conduct Medicaid compliance, payment, provider, and focused audits across diverse provider types.
• Plan and perform audits from development to testing and reporting.
• Research federal/state statutes, Medicaid manuals, policies, and guidelines.
• Develop audit testing procedures addressing identified risks and requirements.
• Analyze claims, payment data, documentation, and records to identify noncompliance.
• Prepare audit findings with applicable requirements, evidence, and financial impact.

Skills

Medicaid audits

Data analysis

Policy interpretation

Excel

Communication

Documentation

Independent judgment

Education

Bachelor's degree in accounting/finance/healthcare

Tools

Excel

Word

PowerPoint

Job description

Medicaid Fraud Auditor

Job Locations

US

Responsibilities

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.

Qualifications

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.

Peraton Overview

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 cannot 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.

Target Salary Range

$66,000 - $106,000. This represents the typical salary range for this position. Salary is determined by various factors, including but not limited to, the scope and responsibilities of the position, the individual's experience, education, knowledge, skills, and competencies, as well as geographic location and business and contract considerations. Depending on the position, employees may be eligible for overtime, shift differential, and a discretionary bonus in addition to base pay.

EEO

EEO: Equal opportunity employer, including disability and protected veterans, or other characteristics protected by law.