Medicaid Audit and Compliance Specialist

Job Description:

• Applies in-depth knowledge of federal and state regulations and healthcare industry standards.
• Comprehends and follows auditing plans and methodologies specific to contract requirements.
• Prioritization and assignment of workload, ensuring adherence to task order policies and procedures.
• Examines and calculates data from financial documents and statements such as provider cost reports as a method of audit.
• Utilize data mining and trend analysis tools to detect anomalies in Medicaid billing and payment patterns.
• Attend on-site audits to retrieve medical records and conduct provider entrance/exit conference.
• Prepare and submit medical record request letters to providers associated with requests for medical record requests or suspension overpayment determinations.
• Interpret and apply pertinent laws, regulations, policies, and procedures relevant to the specific audit findings and provider type being audited.
• Ensure Generally Accepted Government Auditing Standards (GAGAS) standards are applied to each applicable audit to identify fraud, waste or abuse.
• Preparing factual and objective written reports in conformance with professional auditing and evaluation standards and present findings to leadership, external agencies, and government partners.
• Calculates improper payments, and issues findings, recommendations, and corrective actions in accordance with applicable regulations, policies and procedures.
• Prepare and send suspension overpayment determinations to providers when applicable.
• Communicates with federal/state agencies and providers regarding issues such as general regulatory compliance, audit findings, and the recovery process.
• Attends briefings and presentations as assigned.
• Maintains fraud case development quality standards so that proper case development is ensured, and quality cases are fully prepared.
• Maintains proper and timely updates in appropriate tools and applications for their investigations. Case development databases and documents.
• Develops and documents reports of investigative findings, compiles case file documentation, calculates improper payments, and issues findings, recommendations, and corrective actions in accordance with applicable regulations, policies and procedures.
• Program research relating to federal program applications, eligibility, payments, and other program requirements.
• Conducts on-site visits and/or interviews as required for investigation.
• Identify weaknesses in current audit processes and recommend enhancements for improved efficiency and effectiveness.
• Performs ad hoc tasks/duties as assigned.

Requirements:

• Bachelor’s Degree in finance, accounting or related field required.
• 5-7 Years of related experience in finance, accounting, or auditing.
• Intermediate knowledge of internal audit policies and operating principles.
• Intermediate knowledge and experience in auditing Medicare/Medicaid and other government payment and oversight programs. (CMS, HRSA, OIG, DOE, Dept. of Commerce etc.)
• Knowledge and experience in the application of government accounting principles and standards, including Generally Accepted Government Auditing Standards (GAGAS).
• Experienced investigative skills.
• Strong data analysis skills.
• Knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS level II and CPT codes. Utilizes Medicaid and Contractor guidelines for coverage determinations.
• Experience in reviewing claims for appropriate billing and medical coding requirements, performing medical review, and/or developing fraud cases.
• Strong oral and written communication skills, strong interpersonal skills, and superior organizational abilities.
• Ability to take initiative, to maintain confidentiality, to meet deadlines, and to work in a team environment.
• Ability to report work activity on a timely basis.
• Ability to work independently and as a member of a team to deliver high quality work.
• Ability to multitask and prioritize assignments while meeting deadlines.
• Proficiency in Microsoft Office, specifically Microsoft Word and Excel.
• Passion and alignment with IntegrityM’s mission, vision, values and operating principles.

Additional Requirements:

• Must pass post hire background screening checks.

• For remote work, required to have wired and/or wireless internet access.

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