Supervisor - Audit/Investigation

Overview

This role oversees audits and investigations and the associated workload. The position performs in-depth evaluation and makes field-level judgments related to audits/investigations and case compliance matters that involve potential Medicare fraud, waste, and abuse (including Medicare and/or Medicaid). Recommendations support referral to appropriate agency(ies) for administrative action or to law enforcement for criminal action.

Responsibilities

• Review new audits/investigations and/or incoming leads to determine appropriateness and assign to auditors/investigators.
• Vet providers as required with appropriate agency(ies) and law enforcement; supervise the vetting process.
• Review audit/investigation plans and priorities to ensure appropriateness and quality for the specific functions/workload assigned to the team.
• Conduct regular file reviews to ensure audit/investigation plans are appropriate and that audit/investigation file documentation is entered and summarized correctly in case tracking systems.
• Review auditor/investigator requests for information, data, reports, and correspondence to ensure quality and appropriateness.
• Supervise and conduct audit/investigation actions as needed, including interviewing, onsite audit/investigation, and/or site verification.
• Lead audit/investigation projects, including developing an audit/investigation strategy, conducting meetings with stakeholders, reviewing project actions for quality, and documenting findings in reports for management.
• Coordinate with Data and Medical Review departments to support efficient audits/investigations.
• Prepare and present audits/investigations, overpayments, and related questions for stakeholder meetings.
• Document audit/investigation information and file reviews (interviews, events, findings, communications, etc.) in case tracking systems and update systems as needed.
• Determine audit/investigation appropriateness of fraud, waste, and abuse issues in accordance with pre-established criteria.
• Review audit/investigative findings with auditors/investigators and approve the course of action.
• Supervise and prepare the team’s audits/investigations for Major Case Coordination meetings and review them for quality assurance.
• Initiate and maintain communications with law enforcement and appropriate regulatory agencies, presenting audit/investigation findings for their consideration to further audit/investigate, prosecute, or pursue other regulatory/administrative remedies.
• Supervise administrative remedies in accordance with major case coordination direction (e.g., payment suspensions, revocations, provider education) and review for quality assurance.
• Review and approve closing summaries for audits/investigations.
• Collect information and documentation requested by internal and external stakeholders (e.g., CMS, law enforcement, FOIA requests) and submit as required.
• Collaborate with other program integrity contractors as needed.
• Testify at legal or administrative proceedings as necessary.
• Manage team performance through regular, timely feedback and the formal performance review process to support delivery of exceptional services, engagement, motivation, and team development.

Supervision

• Work independently and escalate questions and issues as needed.

Education

• Minimum Bachelor’s Degree required (can be substituted for experience).

Work Experience

• 5–7 years of experience required
• 8–11 years preferred
• Experience can be substituted for education.

Certifications

• Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification preferred

Compensation & Benefits

Not specified.

Location

Not specified.

Equal Opportunity & Workplace Information

• Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.
• Drug-free workplace. Offers of employment are contingent upon successful completion of pre-employment background and drug screens.