Apply📍 United States
🧭 Full-Time
🔍 Healthcare compliance and fraud prevention
- Bachelor’s degree is required.
- Typically 2+ years of related experience in finance, accounting, or auditing.
- Medicaid managed care work experience.
- Intermediate understanding of Medicaid managed care.
- Intermediate knowledge of internal audit policies and operating principles.
- Sufficient writing skills to write a report that clearly identifies any fraud discovered, is easily comprehended, is complete, is thorough, and is accurate and supported by sufficient documentation.
- CPA, CFE, and/or AHFI certification is a plus.
- Used Unified Case Management (UCM) and One PI Business Objects.
- Managed large/varied caseloads.
- Reviewed medical claims and developing fraud cases.
- Applied company policies and procedures in relation to complex investigations.
- Reviewed financial records and advise or assist in the investigation of alleged fraud.
- Experience with statistical sampling and/or advanced statistical training.
- Knowledge of the healthcare industry and medical coding concepts (CPT, ICD-9 / 10, DRGs) and/or experience analyzing health care claims data.
- The Medicaid Auditor will perform audits as assigned, which consist of but are not limited to: Examination of all records, accounts, controls, medical billing and fiscal procedures of a Medicaid service provider.
- Use of audit techniques and procedures to verify the appropriateness of the service provider charges for Medicaid eligible clients/services.
- Maintenance of audit notes and preparation of a written report summarizing the conclusions reached during the audit.
- Tracking and monitoring of assigned workload to ensure all due dates are met.
- Document audit activities and deliverables in external and internal databases.
- Preparation of exhibits such as analyses, graphs, reports, etc., intended to enhance and clarify any audit, which may be complex and hard to understand.
- Perform licensing and exclusion reviews on providers and work with the medical staff to ensure services reimbursed meet regulatory requirements.
- Conduct research on relevant State regulatory support for specific State’s and provider types.
- Review all applicable State policies and regulations associated to each specific audit assignment or algorithm prior to performing audit.
- Understand and maintain the ability to apply regulatory support to the audit findings including ensuring that the citation works for the Provider type being audited.
- Attend on-site audits to retrieve medical records and conduct provider entrance/exit conference.
- Ensure GAGAS standards are applied to each applicable audit to identify fraud, waste or abuse.
- Occasionally go into the field to collect, evaluate, and analyze evidence during an ongoing investigation.
- Occasionally be required to assist in an ongoing investigation by conducting field interviews with investigators of providers and/or beneficiaries or patients witnesses.
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Posted 2024-10-15
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