Fraud Audit & Investigations Specialist

Job not on LinkedIn

🔥 1 minute ago

🇺🇸 United States – Remote

💵 $63k - $83k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🚫👨‍🎓 No degree required

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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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

• Support the FWA Analyst in standard and moderate-complexity fraud, waste, and abuse investigations • Conduct outbound calls and case-related interviews with providers, consumers, caregivers, agencies, health plans, and other involved parties • Review conduct against program requirements, including CDPAP attestations, relationship restrictions, and EVV compliance • Coordinate with analytics, compliance, legal, and account management teams to gather and validate information • Recognize and escalate complex, high-risk, or legally sensitive matters • Assemble and organize case files, referral packages, and supporting documentation • Identify documentation gaps before quality control or external submission • Analyze conflict reports to identify scheduling overlaps and resolve discrepancies • Run and distribute daily and recurring reports • Assemble documentation for regulatory Requests for Information from MFCUs, OMIG, health plans, and other regulators or auditors • Maintain RFI tracking entries, status updates, and deadlines • Coordinate with Legal, Compliance, Risk & Assurance, and Operations on case and RFI documentation • Support external audits and assessment requests • Develop working knowledge of LHCSA operations, MCO/health plan compliance, SIU functions, and state regulator expectations • Support shared investigations and referral processes with MCO/health plan SIU and compliance counterparts • Provide frontline case-handling input when investigative and audit processes are designed or refined

🎯 Requirements

• Bachelor's degree preferred; substantial professional experience may be considered in lieu of a formal degree • 2–3 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 preferred • Experience preparing or responding to regulatory RFIs, audits, or CAP documentation preferred • Experience with consumer-directed care programs such as CDPAP strongly preferred • Strong organizational and documentation skills • Ability to independently assemble accurate, well-organized case files • Ability to support multiple investigations or tasks simultaneously under general direction • Ability to escalate appropriately when complexity exceeds the role's scope • Clear written communication skills • Sound judgment and discretion when handling sensitive or confidential information • Comfort conducting outbound phone conversations about sensitive or confidential matters • Ability to deliver difficult information with professionalism and empathy • Comfort partnering with Analysts, the Senior Manager, and cross-functional stakeholders including compliance, legal, and operations

🏖️ Benefits

• Remote work arrangement • Occasional business travel • Equal opportunity and inclusive workplace