Medicaid Fraud Auditor

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.

What you'll do:

The Medicaid Fraud Auditor will conduct audits and reviews of various Medicaid programs to ensure compliance with federal and state program requirements and to identify exceptions of non-compliance that may result in the recovery of  over-payments. The individual applies advance level of subject matter knowledge to solve a variety of common business issues. Works on problems with moderate to large complex scopes. Acts as an informed team member providing analysis of information and limited project direction input. Exercises independent judgment within defined practices and procedures to determine appropriate action. Follows established guidelines and correctly interprets rules, regulations and other guidance. Evaluates unique circumstances, prepares analytical reviews, identifies exceptions prepare reports, and makes recommendations for corrective action. Specifically, this individual will be tasked with the following:

• Provides research, interpret laws and regulations, performs data analysis and draws conclusions for projects;
• Conducts compliance audits of varied Medicaid case-types, audits claim submissions and performs ad-hoc focused audits;
• Handle several assignments concurrently; organizes and analyzes billing patterns; conducts interviews and obtains statements from beneficiaries/recipients and others;
• Develops an understanding of the function to be audited and uses business knowledge, analytical skills, and experience in identifying findings and making recommendations for improvements;
• Identifies compliance exceptions, conflicts of interest, improper payments;
• Organizes a case file, accurately and thoroughly documents all steps taken;
• Works independently or at times as part of a team, provide ongoing progress reports and updates on audit status;
• Presenting issues of concern, verified through data, citing regulatory violations, proving schemes or scams to defraud the Government;
• Composing correspondence, reports, and referral summary letters;
• Works under general supervision and as a member of a team to deliver high quality work;
• Ensures that projects are timely, complete and accurate; and,
• 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, District of Columbia, and Virginia.

Basic Qualifications:

• Bachelors degree and 5 years or Masters degree with 3 years of relevant experience
• Minimum of 3 years professional work experience in business, healthcare, law enforcement, health science or related field.
• Knowledge of internal audit/investigative policies and operating principles.
• Understanding of Medicare/Medicaid or healthcare auditing.
• Understanding of Medicaid Managed Care Plans preferred
• Research and analytical skills.
• Strong familiarity with Microsoft Office tools, including intermediate to advanced knowledge of Excel.
• US Citizenship required.

Preferred Qualifications:

• Intermediate financial and business acumen.
• Intermediate audit/investigative skills
• Project management skills.
• Knowledge of the healthcare industry and medical coding concepts and/or experience analyzing health care claims data is preferred

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 can’t 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.