Become a part of our caring community
The Fraud and Waste Professional is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving South Carolina's Medicaid Program.
The Fraud and Waste Professional coordinates investigation with law enforcement authorities. Assembles evidence and documentation to support successful adjudication, where appropriate. Conducts on-site audits of provider records ensuring appropriateness of billing practices. Prepares complex investigative and audit reports. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
Responsibilities
Analyze healthcare payment methodologies, billing practices, and reimbursement structures to detect irregularities and support investigative findings.
Assemble, organize, and 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.
Follows established guidelines/procedures.
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.
Support organizational goals by helping improve program integrity, protecting member and provider trust, and enhancing the consumer experience.
Use data analysis and performance metrics to identify trends, outliers, and areas of potential risk. preserve evidence and supporting documentation for successful case resolution and adjudication.
Must reside in South Carolina
Use your skills to make an impact
Required Qualifications
Bachelor's degree
Strong clinical experience to include 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, Word, Excel, Access)
Strong personal and professional ethics
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Must reside in South Carolina
Preferred Qualifications
Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI).
Understanding of healthcare industry, claims processing and investigative process development.
Experience in a corporate environment and understanding of business…