Description
The Fraud and Waste Professional is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving South Carolina's Medicaid Program.
Responsibilities:
- Analyze healthcare payment methodologies, billing practices, and reimbursement structures to detect irregularities and support investigative findings.
- Assemble, organize, and preserve evidence and supporting documentation for successful case resolution and adjudication.
- Communicate findings clearly and professionally, both verbally and in writing, to a variety of audiences.
- Conduct comprehensive investigations of reported, alleged, or suspected fraud, waste, and abuse involving the Medicaid program.
- Coordinate investigations with law enforcement, regulatory agencies, and other internal or external partners, as appropriate.
- Interpret and apply established guidelines, policies, and procedures while exercising sound judgment in ambiguous situations.
- Leverage clinical knowledge across multiple practice areas to evaluate medical necessity, appropriateness of services, and billing practices.
- Maintain accurate case files, audit workpapers, and documentation in accordance with departmental and regulatory standards.
- Manage assigned investigations and audits with minimal direction while meeting deadlines and quality expectations.
- Partner with cross-functional teams to support fraud prevention, recovery efforts, and program integrity initiatives.
- Perform on-site audits of provider records to assess billing accuracy, documentation integrity, and compliance with applicable policies and regulations.
- Prepare detailed, complex investigative summaries, audit findings, and formal reports for internal leadership and external stakeholders.
- Review claims, provider billing patterns, medical records, and related documentation to identify potential fraud, waste, or abuse.
- Use data analysis and performance metrics to identify trends, outliers, and areas of potential risk.
Requirements:
- Bachelor's degree
- Strong clinical experience in multiple practice areas
- At least 2 years of healthcare fraud investigations and auditing experience
- Knowledge of healthcare payment methodologies
- Strong organizational, interpersonal, and communication skills
- Inquisitive nature with ability to analyze data to metrics
- Computer literate (MS Office)
- Strong personal and professional ethics
Benefits:
- Medical, dental, and vision benefits
- 401(k) retirement savings plan
- Time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
- Short-term and long-term disability
- Life insurance