[Hiring] Fraud Audit & Investigations Specialist @Public Partnerships | PPL

Role Description

The Fraud Audit & Investigations Specialist provides administrative and analytical support to the FWA Analyst and Senior Manager, Program Integrity, in conducting fraud, waste, and abuse (FWA) investigations and contributes to the team's audit and regulatory deliverable work. Operating under general direction from the Senior Manager, this role assists with intake, documentation, and tracking of moderate-complexity investigations, helps prepare and organize supporting documentation for regulator-ready case files, and provides support to the Analyst and Senior Manager on more complex, high-risk, or multi-agency matters and on regulatory deliverables.

Key Responsibilities

• Investigations
  • Support the FWA analyst to conduct standard and moderate-complexity investigations into suspected fraud, waste, and abuse referred from analytics, hotline reports, or health plan/regulator referrals.
  • Make routine outbound calls to providers, consumers, caregivers, agencies, health plans, and other involved parties to gather information and conduct case-related interviews, discussing sensitive and confidential matters and following appropriate discretion and privacy protocols before sharing case-specific details.
  • Review provider, consumer, and caregiver conduct against program requirements, including CDPAP-specific issues such as attestations, relationship restrictions, and EVV compliance.
  • Coordinate with cross-functional teams, including analytics, compliance, legal, and account management staff to gather and validate information that drives case resolution.
  • Recognize and escalate complex, high-risk, or legally sensitive matters to the Analyst or Senior Manager.
• Documentation, Quality and Team Support
  • Assemble and organize case files, referral packages, and supporting documentation for assigned cases to meet regulatory sufficiency standards.
  • Help identify and flag documentation gaps in assigned casework prior to formal quality control or external submission.
  • Pull and analyze conflict reports to identify possible scheduling overlaps and collaborate with other teams and appropriate staff to investigate and resolve discrepancies as necessary.
  • Run and distribute daily and recurring reports, and provide general administrative support to the team as needed.
• RFI & Regulatory Deliverable Management
  • Assemble and organize documentation for assigned portions of Requests for Information (RFIs) from MFCUs, OMIG, health plans, and other regulators or auditors, under the direction of the Analyst or Senior Manager.
  • Maintain assigned entries in the RFI tracking log, including status updates and documentation of deadlines.
  • Coordinate with Legal, Compliance, Risk & Assurance, and Operations to gather documentation and data needed for assigned cases and RFIs.
  • Support preparation for external audits and assessment requests as directed.
• Stakeholder & Ecosystem Partnership
  • Develop and apply working knowledge of LHCSA agency operations, MCO/health plan compliance and SIU functions, and state regulator expectations.
  • Support the Analyst and Senior Manager on shared investigations and referral processes with MCO/health plan SIU and compliance counterparts.
  • Provide the frontline case-handling perspective when the team is designing or refining investigative and audit processes.

Qualifications

• 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 (e.g., CDPAP) strongly preferred.

Requirements

• Strong organizational and documentation skills; able to independently assemble accurate, well-organized case files.
• Ability to support multiple investigations or tasks simultaneously under general direction, escalating appropriately when complexity exceeds the role's scope.
• Clear written communication skills; able to produce accurate, professional case documentation for review.
• Sound judgment and discretion when handling sensitive or confidential information.
• Comfortable conducting outbound phone conversations with providers, consumers, caregivers, agencies, and health plans on sensitive or confidential matters, including delivering difficult information with professionalism and empathy.
• Comfortable partnering with Analysts, the Senior Manager, and cross-functional stakeholders including compliance, legal, and operations.

Benefits

• Compensation: $63,000 - $83,000.
• 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.