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Medicaid Fraud Inspector Jobs (NOW HIRING)

Jawonio

QA Specialist

New City, NY · On-site

$62K/yr

... site inspections. • Conduct thorough investigation into various types of incidents both ... the Medicaid Fraud & Abuse clearance process. • On-going training/education as part of ...

Jawonio

QA Specialist

New City, NY · On-site

... inspections. · Conduct thorough investigation into various types of incidents both reportable and ... Medicaid Fraud & Abuse clearance process. · On-going training/education as part of development ...

Tcbhc

Coordinator of IDD Provider Services

Conroe, TX · On-site

$60 - $80/hr

... and for Medicaid and Medicare fraud. Tri-County will check the CARE System to determine if an ... the Inspector General (OIG) List of Excluded Individuals. All applicants are required to ...

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Medicaid Fraud Inspector information

What does a Medicaid Fraud Inspector do?

A Medicaid Fraud Inspector investigates allegations of fraud, waste, and abuse within the Medicaid program. Their responsibilities include reviewing claims, gathering evidence, interviewing witnesses, and collaborating with law enforcement agencies to identify and stop fraudulent activities. They help ensure that Medicaid funds are used appropriately and that providers and recipients comply with all relevant laws and regulations. By preventing fraud, they protect both taxpayers and vulnerable populations who rely on Medicaid services.

What are the key skills and qualifications needed to thrive as a Medicaid Fraud Inspector?

To thrive as a Medicaid Fraud Inspector, you need a strong background in criminal justice, finance, or healthcare, often supported by a relevant degree and investigative experience. Familiarity with data analysis software, case management systems, and knowledge of Medicaid regulations and fraud detection techniques is essential. Attention to detail, critical thinking, and strong communication skills help inspectors effectively analyze evidence and coordinate with law enforcement agencies. These skills ensure accurate identification, investigation, and prevention of fraudulent activities to protect public funds and maintain program integrity.

What are some common challenges faced by a Medicaid Fraud Inspector, and how can they be addressed?

Medicaid Fraud Inspectors often encounter challenges such as navigating complex healthcare regulations, analyzing large volumes of data, and dealing with uncooperative individuals during investigations. Staying current with ever-evolving policies and maintaining attention to detail are crucial for success in this role. Collaborating closely with legal teams, healthcare providers, and law enforcement helps address these challenges and ensures thorough investigations. Ongoing professional development and training in investigative techniques can also support inspectors in overcoming these obstacles.

What is the difference between Medicaid Fraud Inspector vs Medicaid Investigator?

AspectMedicaid Fraud InspectorMedicaid Investigator
CredentialsTypically requires certifications like CFE or CPAOften requires similar certifications, sometimes with additional law enforcement credentials
Work EnvironmentGovernment agencies, healthcare compliance departmentsLaw enforcement agencies, government offices
Employer & IndustryState Medicaid agencies, healthcare organizationsState or federal law enforcement, Medicaid fraud units
Search & Comparison IntentHigh overlap in fraud detection and compliance rolesFocuses more on investigation and enforcement actions

Medicaid Fraud Inspectors primarily focus on auditing and detecting fraud within Medicaid programs, often working in compliance roles. Medicaid Investigators tend to conduct in-depth investigations, often with law enforcement authority. Both roles require similar credentials and work within government or healthcare settings, but their core functions differ in scope and enforcement authority.

How hard is it to become a Medicaid Fraud Inspector?

Becoming a Medicaid Fraud Inspector typically requires a background in criminal justice, auditing, or healthcare compliance, along with relevant experience. Many positions require a bachelor's degree and knowledge of Medicaid policies, with some roles benefiting from certifications such as Certified Fraud Examiner (CFE). The process involves applying for government or agency positions, passing background checks, and sometimes completing specialized training.

How to become a Medicaid Fraud Inspector?

To become a Medicaid Fraud Inspector, candidates typically need a bachelor's degree in criminal justice, healthcare administration, or a related field. Relevant experience in auditing, investigations, or healthcare compliance, along with knowledge of Medicaid policies, is important; some roles may require certification such as the Certified Fraud Examiner (CFE). Professional skills in investigation, data analysis, and attention to detail are essential for success in this role.

What qualifications do you need to be a Medicaid Fraud Inspector?

To become a Medicaid Fraud Inspector, candidates typically need a bachelor's degree in criminal justice, healthcare administration, or a related field. Relevant experience in auditing, investigations, or healthcare compliance, along with knowledge of Medicaid policies and regulations, is also important; some roles may require certification such as the Certified Fraud Examiner (CFE).
More about Medicaid Fraud Inspector jobs

What cities are hiring for Medicaid Fraud Inspector jobs?

Cities with the most Medicaid Fraud Inspector job openings:

What states have the most Medicaid Fraud Inspector jobs?

States with the most job openings for Medicaid Fraud Inspector jobs include:

What are popular job titles related to Medicaid Fraud Inspector jobs?

For Medicaid Fraud Inspector jobs, the most frequently searched job titles are:

Medicaid Fraud Inspector jobs near you
Infographic showing various Medicaid Fraud Inspector job openings in the United States as of September 2026, with employment types broken down into 1% As Needed, 80% Full Time, 18% Part Time, and 1% Contract. Highlights an 87% Physical, 3% Hybrid, and 10% Remote job distribution.

Director, Medicaid Program Integrity - Remote

Phoenix, AZ • On-site

Reliant Medical Group
Health Care and Social Assistance • 1 - 5K employees
Learn more about Reliant Medical Groupexternal

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Retirement

This job post has expired today. Applications are no longer accepted.

Reliant Medical Group rating

7.3

Company rating: 7.3 out of 10

Based on 26 frontline employees who took The Breakroom Quiz

Job description

Medicaid Program Integrity Leader

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together.

The Medicaid Program Integrity Leader is responsible for developing, implementing, and overseeing Optum's Medicaid program integrity strategies to assist State Agencies compliance with federal and state Medicaid regulations while preventing, detecting, and addressing fraud, waste, and abuse (FWA). This leader drives operational excellence through data analytics, audits, product insight, and collaboration with internal and external stakeholders. The role balances regulatory compliance, financial stewardship, and member/provider experience to safeguard Medicaid program resources.

You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Primary Responsibilities:

  • Strategic Leadership
    • Develop and execute the organization's Medicaid Program Integrity strategy
    • Establish goals, KPIs, and performance metrics aligned with organizational objectives
    • Lead program integrity operations across pre-payment, post-payment, and support development of new business operations
    • Serve as a subject matter expert on Medicaid integrity requirements and emerging regulatory guidance
  • Compliance & Regulatory Oversight
    • Ensure compliance with CMS, state Medicaid agencies, Office of Inspector General (OIG), and contractual requirements
    • Oversee preparation for audits, investigations, and regulatory reviews
    • Interpret federal and state regulations and translate them into operational policies and procedures
    • Maintain effective controls to support compliance and risk mitigation
    • Present findings, risks, and recommendations to executive leadership and governing committees
  • Data Analytics & Risk Management
    • Leverage advanced analytics to identify billing anomalies, emerging fraud schemes, and utilization trends
    • Establish predictive and retrospective monitoring programs
    • Utilize data-driven approaches to prioritize investigations and maximize recoveries
    • Monitor program integrity performance through dashboards and executive reporting
  • Financial Stewardship
    • Manage program integrity budgets and resources
    • Identify opportunities for cost avoidance, recoveries, and operational efficiencies
    • Quantify savings and return on investment for program integrity initiatives
    • Report financial outcomes to executive leadership
  • Team Leadership
    • Lead multidisciplinary teams including data analysts, developers, business analysts
    • Foster a culture of accountability, collaboration, and continuous improvement
    • Develop succession plans and talent management strategies
    • Mentor leaders and staff to strengthen organizational capabilities

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • 5+ years of healthcare, Medicaid, compliance, audit, investigations, or program integrity experience
  • 5+ years of leadership experience managing teams and complex programs
  • 5+ years of experience with fraud, waste, and abuse investigations and audit programs
  • 2+ years of experience with Medicaid managed care regulations, CMS guidance, and program integrity requirements
  • 2+ years of experience in data analytics and reporting capabilities
  • Excellent communication, executive presentation, and stakeholder management skills
  • Ability to travel up to 25%

Preferred Qualifications:

  • Certified Fraud Examiner (CFE), Certified Compliance & Ethics Professional (CCEP), Certified Internal Auditor (CIA), or similar certification
  • Experience with managed care organizations (MCOs), state Medicaid agencies, or healthcare payers
  • Knowledge of advanced analytics, predictive modeling, and AI-enabled fraud detection

Key Competencies:

  • Strategic Leadership
  • Regulatory Expertise
  • Fraud, Waste & Abuse Prevention
  • Healthcare Analytics
  • Risk Management
  • Financial Acumen
  • Executive Communication
  • Change Management
  • Team Development
  • Stakeholder Engagement

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $134,600 - $230,800 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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