TBI MEDICAID FRAUD AUDITOR - 08122026-79993

Location: Nashville, TN – Tennessee Bureau of Investigation (T.B.I), Medicaid Fraud Control Division – TBI Headquarters

Pay

$6,544 – $10,363 per month ($78,528 – $124,356 annually)

Qualifications

• Bachelor’s degree and 4 years of experience with a healthcare insurance provider (MCO), TennCare, Center for Medicare and Medicaid Services (CMS), Unified Program Integrity Contractors (UPIC), a Medicaid Fraud Control department, or related field.
• OR Associate’s degree and 6 years of experience in the same fields plus a nationally recognized certification as an Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or other relevant certification.
• OR High school diploma or equivalent and 8 years of experience in the same fields plus a nationally recognized certification as an Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or other relevant certification.

Valid driver’s license with no DUI, reckless driving, license suspension for moving violations, or more than 4 moving violations in the past five years.

Responsibilities

• Review and screen potential fraud leads generated through data-mining tools to determine credibility and prepare formal fraud referrals.
• Evaluate tips and referrals from internal and external sources (e.g., TennCare Office of Program Integrity, Adult Protective Services, TBI-MFCD Hotline, Managed Care Organizations, NAMFCU) to determine whether investigative action is warranted.
• Audit financial records, including bank and tax documents, to support civil and criminal Medicaid fraud investigations.
• Analyze claims data and prepare summary reports using Controlled Substance Monitoring Database (CSMD), TennCare billing, Dental and Pharmacy Benefits Managers (PBMs) data, etc., to support investigations.
• Review and audit Electronic Health Records (EHR)/Electronic Medical Records (EMR) and patient-abuse referral reports for evidence relevant to Medicaid fraud cases.
• Identify anomalies, outliers, and trends in medical, financial, and claims data to detect potential fraudulent activity.
• Analyze personally identifiable information (PII) to identify subjects, victims, and potential witnesses in investigations.
• Exchange investigative information with state and federal partner agencies to support coordinated Medicaid fraud enforcement efforts.

Skills

• Decision Quality
• Manages Complexity
• Resourcefulness
• Instills Trust
• Communicates Effectively
• Writing
• Reading Comprehension
• Monitoring

Knowledge & Abilities

• Law and Government
• Medicine and Dentistry
• Written Comprehension
• Deductive Reasoning
• Information Ordering

Tools & Equipment

• Computer
• Telephone
• Copy/Fax/Scanner