Fraud Analyst Jobs in Madison, WI (NOW HIRING)

Position Summary and Job Duties This position within the Children's Long-Term Support (CLTS) Program has analyst responsibilities in the areas of program compliance and project management. The Analyst assists with key responsibilities including coordinating quality assurance efforts, compliance monitoring, policy management, and continuous quality improvement activities. This also includes monitoring program compliance with county, state, and federal requirements; conducting record reviews and audit activities; coordinating policy development and implementation; managing Notices of Adverse Action and appeals processes; facilitating high-cost project reviews and outlier rate requests; and supporting program performance measurement through data analysis and reporting.

Supports and promotes the Mission, Vision, and Guiding Principles of the Human Services Department. Performs duties in a manner consistent with departmental professional standards, "Commitment to Co-Workers", and organizational values. 30%- Program Systems, Compliance, and Quality Assurance Track participant compliance requirements including recertifications, functional screens, assessments, ISP reviews, enrollment timelines, and other required documentation.

Review participant records and data systems to ensure accuracy, completeness, and compliance with county, state, and federal requirements. Facilitate audit activities, including MetaStar record reviews, and coordinate remediation efforts. Serve as a liaison with state agencies and technical support entities regarding program operations, systems, and compliance requirements.

Assist with local requirements in regard to Medicaid Compliance 30%-Project Management and Operational Support Review referrals for adverse actions, analyze participant records and supporting documentation, and determine compliance with CLTS policy and Deciding Together requirements. Draft, issue, and track Notices of Adverse Action (NOAs), ensure adherence to regulatory timelines and notice requirements, and provide support and coordination related to participant appeals. Coordinate the review, development, revision, and implementation of program policies and procedures to ensure alignment with state requirements and program operations.

Facilitate the CLTS Policy Workgroup by scheduling meetings, preparing materials, documenting discussions and decisions, tracking action items, and communicating approved changes to staff and leadership. Coordinate the High-Cost Review Panel process, including scheduling and facilitating meetings, preparing and collecting required documentation, documenting recommendations and decisions, tracking action items, and providing technical assistance to staff. Manage high-cost project tracking and complete required submissions, notifications, and supporting documentation within state systems to ensure compliance with waiver requirements and established timelines.

Assist staff and providers with outlier rate applications and renewals, including gathering documentation, submitting required materials, and serving as the primary point of contact throughout the review process. Track dual CLTS/CCS enrollments and referrals to support program collaboration and coordination. Coordinate other special projects and initiatives that support program goals and operational effectiveness.

10%- Data Analysis, Reporting, and Program Performance Collect, analyze, and maintain program data to evaluate performance, identify trends, and support decision-making. Prepare reports, dashboards, and recommendations for supervisors, management, and stakeholders. Monitor key performance indicators and quality measures to assess program effectiveness and identify opportunities for improvement.

Develop and administer surveys and other feedback tools to evaluate participant experiences and program outcomes. Track and analyze enrollment, eligibility, and performance data and prepare reports to support program oversight, quality assurance, and operational decision-making. 10%- Training, Resource Management, and Continuous Improvement Develop and maintain program resources, forms, guides, policies, and training materials.

Coordinate staff communication and training related to policy updates, process changes, and system enhancements. Maintain shared program resources and reference materials in Teams to ensure staff have access to current information. Support continuous quality improvement efforts through process evaluation, project management, and implementation of operational enhancements.

Provide cross-functional support and coverage for analyst responsibilities to ensure continuity of program operations during staffing shortages, vacancies, workload fluctuations, and special initiatives. 10% - Medicaid Fraud, Waste, and Abuse Monitoring Review as requested participant, provider, and billing activities to identify potential fraud, waste, abuse, or misuse of Medicaid-funded services. Review service utilization, provider billing, and authorization information to ensure services are delivered as approved and in accordance with CLTS policy and Medicaid requirements.

Investigate compliance concerns, implement corrective administrative actions when appropriate, and coordinate referrals to DHS, OIG, or other authorized entities for suspected fraud or abuse. Support program integrity initiatives through ongoing monitoring, education, and collaboration with staff, providers, and fiscal partners. 10% - Analyst Coverage, Program Support, and Special Projects Assist with Notices of Adverse Action, policy and procedure development, data analysis, compliance monitoring, and other analyst functions as assigned.

Participate in program workgroups, operational improvement initiatives, and special projects that support program goals and regulatory compliance. Provide cross-functional support and coverage for analyst responsibilities to ensure continuity of program operations during staffing shortages, vacancies, workload fluctuations, and special initiatives. Provide temporary case management coverage, including completion of required contacts, documentation, assessments, authorizations, and other service coordination activities, as needed to support program operations.

Success Factors (KSA's) Knowledge of Human Services Programs & Medicaid Ability to prepare and organize documents and to present facts clearly and concisely, orally and in writing Attention to detail and accuracy Ability to problem solve, quantitatively or qualitatively define problems and find solutions Ability to effectively communicate in writing to a wide variety of audiences Ability to work with others, prioritize duties, multi-task, work under deadlines, and be flexible and adaptive Ability to establish and maintain effective working relationships with co-workers, officials, providers, and the general public Experience utilizing computer software tools, such as spreadsheets and databases Job Requirements, Education, Training & Experience Bachelors Degree from an accredited college or university with major coursework in social work, public administration, or a human services related field. Essential Job Functions (physical elements, equipment and working conditions) Physical elements: - Ability to stand, walk and sit. - Ability to exert up to 20 lbs of force occasionally or up to 10 lbs of force frequently Equipment use: - Ability to use computer and computer keyboard.

- Ability to use standard office equipment. Working conditions: - Almost all indoor work in an office setting