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Title:

CFE/Special Investigator/Healthcare Auditor - REMOTE

Overview:

Performs evaluation and development of leads, complaints, and/or investigations to verify allegations of potential appropriate administrative actions

Satisfactory completion of Background Check required

Job Summary

Seeking a full-time, remote, Program Integrity Analyst II to assist with investigations and administrative actions relating to Medicare/Medicaid claims.

Essential Duties and Responsibilities

Perform evaluation and development of leads, complaints, and/or investigations to determine if further investigation and administrative actions are warranted

Conduct independent reviews resulting from the discovery of situations that potentially involve fraud or abuse

Utilize basic data analysis techniques to detect aberrancies in Medicare and Medicaid claims data, and proactively seeks out and develops leads/investigations received from a variety of sources (e.g., CMS, OIG, 1-800-MEDICARE, and fraud alerts)

Review information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare and Medicaid policies and initiate appropriate action

Make potential fraud determinations by utilizing a variety of sources such as internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid regulations, and the Social Security Act

Compile and maintain documentation and information related to investigations, cases, and/or leads

Participate in onsite audits in conjunction with investigation development

Develop and prepare potential Fraud Alerts and program vulnerabilities for submission to CMS. Share information on current fraud investigations with other Medicare contractors and state Medicaid agencies, law enforcement, and other applicable stakeholders

Prepare and submit external correspondence and reports, including, but not limited to, overpayment letters, fraud case referrals, suspensions, rebuttals, Medicare/Medicaid findings, reports, and administrative action recommendations

Submit suspension notifications to providers upon suspension approval

Prepare and submit ADR letters to providers associated with requests for medical record requests or suspension overpayment determinations

Serve as mentor/trainer to new Program Integrity staff

Perform other duties as assigned by PI Supervisor or PI Manager that contribute to task order goals and objectives

Competencies

Excellent research and organization, prioritization, and time management skills

Excellent verbal and written communication skills

Ability to work independently with minimal supervision

Ability to multi-task in a fast-paced environment

Knowledge of statistics, data analysis techniques, and PC skills are preferred

Education and Experience

College degree required related to the position (i.e. criminal justice, statistics, data analytics, etc.

Experience in program integrity investigations/detection, audits, insurance or a related field that demonstrates expertise in reviewing, analyzing/developing information and making appropriate decisions

Preference given to individuals that have attained a Certified Fraud Examiner (CFE) designation

Salary/Benefits

The salary range for this role is TBD and negotiable, commensurate with experience,

education, qualifications, certification, geographic location and business or organizational needs.

Benefits include Medical, Dental & Vision, Life, LTD and STD, 401(k) with company match and paid

time off.

About Us:

Wise Care Counts (WCC, LLC) helps government agencies protect and optimize public health benefits programs through clinically informed, data-driven solutions that are impactful, proportionate, and defensible. With nearly 20 years of experience, we support federal and state programs through compassionate workers’ compensation case management, payment validation services, and improper payment assessments for programs including FECA, Medicare, and Medicaid.

As a woman-owned small business based in Fairfax, Virginia, we are committed to integrity, sound decision-making, operational excellence, and preserving trust in the public programs that millions rely on. We value professionals who are proactive, adaptable, detail-oriented, and passionate about supporting meaningful work that makes a difference.

WCC is an Equal Opportunity Employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, caste, disability, veteran status, and other legally protected characteristics and maintain a drug-free workplace.

To apply, please send your resume and a brief introduction outlining your experience and interest in the role.