Fraud Audit & Investigations Analyst

Job Summary

The Program Integrity Fraud Audit & Investigations Analyst conducts fraud, waste, and abuse (FWA) investigations and serves as the team's lead for quality control and regulatory deliverable readiness. This role investigates suspected FWA, audits and quality-checks case files and referral packages for completeness and regulatory sufficiency and owns the preparation and packaging of materials in response to Requests for Information (RFIs) from regulators, health plans, and law enforcement. With a broad view of the Medicaid ecosystem, spanning LHCSA/provider agency operations, MCO/health plan processes, and regulator expectations, this person ensures investigations and audit deliverables meet the standards of OMIG, MFCUs, health plan partners, and other oversight bodies.

Key Responsibilities

Investigations

• Conduct and/or support investigations into suspected fraud, waste, abuse, neglect, and exploitation referred from analytics, hotline reports, or health plan/regulator referrals
• Interview witnesses, gather and preserve evidence, and document findings in accordance with investigative standards and chain-of-custody practices
• Assess provider, consumer, and caregiver conduct against program requirements, including CDPAP-specific issues such as attestations, relationship restrictions, and EVV compliance
• Partner with the analytics function to validate and further develop data-driven leads into case-ready findings
• Prepare case summaries, findings, and referral recommendations for the Senior Director and, as applicable, external agencies

Audit & Quality Control

• Perform quality control review of case files, referrals, and investigative documentation for completeness, accuracy, and regulatory sufficiency
• Audit adherence to internal investigative protocols, SOPs, and documentation standards
• Analyze documentation and operational processes to assess compliance with established requirements, identify potential risks, and propose solutions for process improvements.
• Identify and remediate documentation gaps prior to internal sign-off or external submission
• Support internal audit-readiness reviews of the Program Integrity function

RFI & Regulatory Deliverable Management

• Serve as the lead for compiling, organizing, and quality-checking response packages for Requests for Information from MFCUs, OMIG, health plans, and other regulators or auditors
• Ensure RFI responses are complete, accurate, well-organized, and appropriately documented; track deliverables and timelines to support timely submission and resolution.
• Coordinate cross-functionally (Legal, Compliance, Risk & Assurance, Operations) to gather required documentation and data
• Maintain a tracking log of all open and closed RFIs, including status, owners, and deadlines
• Support preparation for external audits and assessment requests in partnership with the Risk and Assurance team

Stakeholder & Ecosystem Partnership

• Serve as a subject matter expert with working knowledge of LHCSA agency operations, MCO/health plan compliance and SIU functions, and state regulator expectations
• Partner with MCO/health plan SIU and compliance counterparts on shared investigations and referral processes
• Support the Senior Director in maintaining relationships with regulators, MFCUs, and law enforcement partners
• Provide the frontline and health plan perspective when designing or refining investigative and audit processes

All other duties assigned

Required Skills:

• 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; experience across more than one of these perspectives is a strong plus
• Working knowledge of Medicaid program requirements, including consumer-directed care programs (e.g., CDPAP)
• Excellent organizational and documentation skills; comfortable assembling audit-ready, regulator-facing materials
• Ability to manage multiple investigations, audits, and RFIs simultaneously under deadline pressure
• Strong written communication skills; able 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

Qualifications:

Education:

Bachelor's degree preferred; substantial professional experience may be considered in lieu of a formal degree.

Substantial professional experience in a related field may be considered in lieu of formal degree.

Experience:

• 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 (e.g., CDPAP) strongly preferred

Certification: CFE, AHFI, or CCEP preferred but not required.

Working Conditions:

Remote work with occasional business travel

Supervisory Responsibility (If applicable):

None (individual contributor); TBD as team scales.

Compensation: $77,500 - $99,000

This role is eligible for a base salary within the posted range. Actual compensation will be determined based on a variety of factors, including skills, experience, and geographic location. Compensation may vary for positions based in high cost-of-labor markets.

The above is intended to describe the general contents and requirements of work being performed by people assigned to this classification. It is not intended to be construed as an exhaustive statement of all duties, responsibilities, or skills of personnel so classified