Fraud Audit & Investigations Analyst

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $77.5k - $99k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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Public Partnerships | PPL

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

🤝 B2B

Healthcare Insurance • B2B

Public Partnerships | PPL is a provider of financial management and administrative services that enable self-directed Medicaid long-term care. The company helps eligible Medicaid participants hire and manage caregivers (including family or friends), handles payroll, payments, tax and compliance paperwork, and offers online tools and support to participants, caregivers, and program administrators. PPL partners with state Medicaid agencies and managed care organizations to administer self-directed care programs across multiple states, aiming to simplify program administration and keep people in their homes.

📋 Description

• Conduct and/or support investigations into suspected fraud, waste, abuse, neglect, and exploitation • Interview witnesses, gather and preserve evidence, and document findings according to investigative standards and chain-of-custody practices • Assess provider, consumer, and caregiver conduct against program requirements, including CDPAP attestations, relationship restrictions, and EVV compliance • Partner with analytics to validate and develop data-driven leads into case-ready findings • Prepare case summaries, findings, and referral recommendations • Perform quality-control reviews of case files, referrals, and investigative documentation • Audit adherence to investigative protocols, SOPs, and documentation standards • Analyze documentation and operational processes to assess compliance, identify risks, and propose process improvements • Identify and remediate documentation gaps before internal sign-off or external submission • Support internal audit-readiness reviews of the Program Integrity function • Compile, organize, and quality-check RFI response packages for MFCUs, OMIG, health plans, and other regulators or auditors • Track RFI deliverables, timelines, status, owners, and deadlines • Coordinate with Legal, Compliance, Risk & Assurance, and Operations to gather documentation and data • Support external audits and assessment requests • Partner with MCO/health plan SIU and compliance counterparts on shared investigations and referral processes • Support relationships with regulators, MFCUs, and law enforcement partners • Provide frontline and health plan perspective when designing or refining investigative and audit processes • Perform other duties as assigned

🎯 Requirements

• Demonstrated experience investigating and/or auditing fraud, waste, and abuse in a Medicaid or healthcare setting • Familiarity with LHCSA agency operations, MCO/health plan compliance or SIU functions, and state or federal regulator expectations • Working knowledge of Medicaid program requirements, including consumer-directed care programs such as CDPAP • Excellent organizational and documentation skills • Ability to manage multiple investigations, audits, and RFIs simultaneously under deadline pressure • Strong written communication skills and ability to produce clear, defensible, and professional case and audit documentation • Sound judgment and discretion when handling sensitive or confidential information • Comfortable partnering across compliance, legal, operations, and external stakeholders • Bachelor's degree preferred; substantial professional experience may be considered in lieu of a formal degree • 5–7 years of combined experience across LHCSA, MCO/health plan, and/or state regulatory Medicaid roles • Prior experience in fraud investigations, program integrity, or compliance auditing required • Experience preparing or responding to regulatory RFIs, audits, or CAP documentation preferred • Experience with consumer-directed care programs such as CDPAP strongly preferred • CFE, AHFI, or CCEP preferred but not required

🏖️ Benefits

• Remote work with occasional business travel