Medicaid Fraud Auditor Team Lead

Peraton; Northern (KY); Hybrid; USD 90,000 - 110,000; Full time

Job summary

SafeGuard Services (SGS), a subsidiary of Peraton, seeks a Medicaid Fraud Auditor Team Lead to join our remote team. The role focuses on guiding Medicaid audits, ensuring quality, and mentoring staff within the Northeast jurisdiction. Requires extensive audit leadership experience and Medicaid expertise.

The position emphasizes independent judgment, adherence to audit methodologies, and timely completion of findings, with opportunities to influence program integrity outcomes.

Qualifications

• Minimum 8 years with BS/BA; or 12 years with HS diploma/equivalent.
• Experience leading staff in identifying noncompliance, improper payments, or overpayments.
• Experience auditing Medicaid, Medicare, healthcare, or program integrity.
• US Citizen required.

Responsibilities

• Oversee development and progression of audits from initiation to completion.
• Provide day-to-day oversight for Auditors conducting Medicaid audits.
• Offer technical guidance on Medicaid requirements, methodology, and findings.
• Review workload and perform QC for staff during meetings.
• Monitor staff workloads and audit metrics alignment.
• Mentor team to detect fraud, waste, or abuse.
• Act as a point of contact for manager.

Skills

Audit team leadership

Regulatory knowledge Medicaid/Medicare

Strong communication

Microsoft Office

Staff mentoring

Public sector compliance

Education

Bachelor's degree or higher

High School Diploma or equivalent

Tools

Microsoft Office

Job description

Basic Qualifications:

• Minimum of 8 years with BS/BA; or 12 years with a HS Diploma/equivalent
• Experience conducting Medicaid, Medicare, healthcare, compliance, financial, internal, or program integrity audits.
• Experience leading staff in identifying and documenting noncompliance, improper payments, billing irregularities, or potential overpayments.
• Strong written, verbal communication and organization skills.
• Strong PC knowledge and Microsoft Office tools.
• 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 preferred.

SafeGuard Services (SGS), a subsidiary of Peraton, performs audits, investigations, data analysis, and medical reviews to detect, prevent, deter, reduce fraud, waste, and abuse.

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

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.

What You'll do:

As an Audit Team Lead, this individual's primary responsibilities include achieving quality objectives, providing day-to-day workload oversight to promote timely development and resolution of Medicaid audits and providing mentoring and guidance to Audit team members. The individual exercises significant independent judgment within broadly defined policies and practices to determine the best method for accomplishing work and achieving objectives within established timelines.

• Oversee the development and progression of audits from initiation through completion, including planning, audit testing, analysis, findings, provider communications, and issuance of final finding reports.
• Provide day-to-day oversight and direction for assigned Auditors conducting Medicaid audits. The Team Lead is responsible for ensuring that audits are appropriately planned, progressed, documented, reviewed, and completed in accordance with applicable federal and state Medicaid requirements, established audit methodologies.
• Provide technical guidance and consultation to Auditors regarding Medicaid requirements, audit methodology, regulatory interpretation, claims analysis, documentation, and development of findings.
• Review individual workload during monthly auditor meetings; assist with prioritizingand conduct QC for staff.
• Establish priorities and monitor staff workloads to ensure resources are appropriately aligned with audit requirements and metrics.
• Monitor the quality of WMM/UCM.
• Monitor timeliness for audit updates and escalated to management as necessary.
• Mentor team members so that they can identify previously undetected fraud, waste, or abuse through proactive or reactive research, analysis, and development.
• Act as a point of contact for manager.

Essential Functions Include:

• Ability to perform research and draw conclusions
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
• Ability to organize a case file, accurately and thoroughly document all steps taken
• Ability to compose correspondence, reports and referral summary letters
• Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters
• Ability to communicate effectively, internally and externally
• Ability to interpret laws and regulations
• Ability to exercise independent judgment while working within established policies, procedures, and audit methodologies.
• Ability to work with staff managing multiple assignments, establishing priorities, meeting deadlines, and maintaining accurate audit documentation.
• Ability to handle confidential material
• Ability to report work activity on a timely basis
• Ability to work independently and as a member of a team to deliver high-quality work
• Ability to attend meetings, training, and conferences, overnight travel required
• Document QC results in WMM according to record type
• Coordinate with other designated leads, if necessary, for coverage for periods where the lead is out of the office during work hours.