Fraud Audit & Investigations Analyst

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Public Partnerships LLC supports individuals with disabilities or chronic illnesses and aging adults, to remain in their homes and communities and “self” direct their own long-term home care. Our role as the nation’s largest and most experienced Financial Management Service provider is to assist those eligible Medicaid recipients to choose and pay for their own support workers and services within their state-approved personalized budget. We are appointed by states and managed healthcare organizations to better serve more of their residents and members requiring long-term care and ensure the efficient use of taxpayer funded services.
Our culture attracts and rewards people who are results-oriented and strive to exceed customer expectations. We desire motivated candidates who are excited to join our fast-paced, entrepreneurial environment, and who want to make a difference in helping transform the lives of the consumers we serve. (learn more at www.pplfirst.com).
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

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.
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.
Working Conditions:
Remote work with occasional business travel
Supervisory Responsibility (If applicable):
N/A
Compensation Range: $77,5000 - $99,000 / annually
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
PPL is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PPL, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PPL will not tolerate discrimination or harassment based on any of these characteristics.
If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!
Originally posted on Himalayas