Remote Fraud Investigator—Medicaid Integrity

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

Job summary

Peraton is seeking a Fraud Investigator/Auditor to manage the full lifecycle of potential fraud, waste, and abuse within Medicaid program integrity. The role involves intake, vetting, investigations, and administrative actions across CMS and state agencies from a remote location in the NE jurisdiction.

The ideal candidate will perform in-depth provider audits, document findings, and coordinate with interagency partners to ensure program integrity and recover taxpayer dollars.

Qualifications

• 5 years with BS/BA or 3 years with a Masters Degree.
• Strong investigative skills.
• Strong communication and organization skills.
• Must be a US Citizen.

Responsibilities

• Receive complaints, referrals, and leads from multiple sources including CMS, state agencies, managed care organizations, law enforcement, and the public.
• Perform intake assessment to determine jurisdiction, scope, and preliminary validity of the allegations.
• Conduct preliminary analysis of provider data, billing patterns, and case documentation to verify accuracy and completeness.
• Vet matters by checking for ongoing or prior reviews, ensuring issues are not duplicative or outside contractual scope.
• Perform deconfliction with partner agencies to ensure investigative efforts are not duplicative, and to determine lead ownership.
• Document vetting outcomes including reference numbers, case status, partner contacts, and rationale for continuation, reassignment, or closure.
• Perform in-depth provider audits and investigations, including claims analysis, medical record reviews, and interviews.
• Identify billing irregularities, documentation gaps, or systemic vulnerabilities indicating fraud, waste, or abuse.
• Develop investigative findings with supporting evidence for potential administrative, civil, or criminal action.
• Draft, recommend, and process administrative remedies including payment overpayment determinations, and referrals.
• Prepare clear, defensible reports to CMS, state agencies, and/or law enforcement partners in accordance with policy and regulatory requirements.
• Support partner agencies with rebuttals, appeals, and settlements related to administrative findings.
• Maintain accurate, timely, and comprehensive documentation of case activity in designated tracking systems.
• Ensure compliance with CMS Program Integrity Manual and state regulations.
• Contribute to reports, dashboards, and metrics that track case outcomes and recoveries.

Skills

Strong investigative skills

Strong communication

Strong organizational skills

US Citizenship

PC proficiency

Education

BS/BA in related field

Masters Degree

Tools

Data systems

Job description

Peraton is seeking a Fraud Investigator/Auditor to manage the full lifecycle of potential fraud, waste, and abuse within Medicaid program integrity. The role involves intake, vetting, investigations, and administrative actions across CMS and state agencies from a remote location in the NE jurisdiction.

The ideal candidate will perform in-depth provider audits, document findings, and coordinate with interagency partners to ensure program integrity and recover taxpayer dollars.