Supervisor - Audit and Investigation

Job Overview

This role involves overseeing the audit and investigation workflow focused on Medicare fraud, waste, and abuse, along with compliance cases related to Medicare and Medicaid. The supervisor evaluates audits/investigations deeply, makes field-level decisions, and coordinates referrals to agencies or law enforcement for action.

Primary Responsibilities

• Evaluate new audit and investigation cases or leads, assign tasks to team members, coordinate provider vetting with agencies and law enforcement, and supervise this vetting process.
• Review audit and investigation plans to ensure they meet quality standards appropriate to assigned workload.
• Conduct routine file reviews to confirm proper documentation and case tracking; approve information requests from auditors and investigators.
• Lead audit/investigation activities, including interviews, onsite verifications, and managing audit strategies; organize stakeholder meetings, assess project quality, and compile reports for management.
• Coordinate with Data and Medical Review teams to streamline audit processes and prepare materials for stakeholder discussions concerning overpayments or other issues.
• Maintain detailed documentation of all audit/investigation actions in case tracking systems; monitor compliance with criteria for fraud, waste, and abuse findings; oversee preparation and quality review of cases for major coordination meetings.
• Liaise with law enforcement and regulatory bodies to present findings, support prosecutions or regulatory actions, and supervise administrative remedies such as payment suspensions or provider education.
• Gather and submit required documentation in response to requests from CMS, law enforcement, or FOIA inquiries.
• Collaborate with other program integrity contractors as needed.
• Provide testimony in legal or administrative proceedings when required.
• Manage team performance via regular feedback and formal reviews to ensure high service quality, engagement, and professional growth.

Supervision and Autonomy

The position requires independent work with escalation of issues as necessary.

Qualifications

• Minimum of a Bachelor's degree; experience may substitute education.
• Experience ranging from 5 to 7 years required; 8 to 11 years preferred.
• Certifications such as Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator are preferred but not mandatory.