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Investigative Auditor

Neighborhood Health Plan of Rhode Island • Smithfield, RI, US • published 2026-11-03 09:17:09.159127

Description

The Investigative Auditor is responsible for the intake, triage, review, and documentation of Fraud, Waste, and Abuse (FWA) allegations referred to the Special Investigations Unit (SIU) team and conducts respective audits. Following an independent review of the allegations, the Investigative Auditor will determine whether to recommend closing referrals that lack sufficient supporting evidence or to advance the matter to an audit, as warranted by the initial findings. This position may also monitor and analyze patterns of utilization and/or potentially fraudulent activities through prepayment claims reviews, post payment auditing and/or provider record review, ensuring claims, medical records and other documentation submitted to the company in relation to reimbursement are in compliance with all federal and state regulatory guidelines, contractual requirements and/or industry standards. Assists in the recovery of funds lost due to FWA and reports cases of suspected fraud to the Office of Program Integrity. Manages regulatory notices (HPMS memos), case summaries and coordinates with external entities, including but not limited to federal, state and local agencies and law enforcement....

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