Job Description
In this role, the Medicaid Auditor III will be responsible for performing and reporting on Medicaid Managed Care Plans and providers to identify potential fraud, waste, and abuse; issue findings and recommendations; and identify improper payments. Audit assignments can be programmatic or financial and may range from desk reviews and/or onsite review activities as determined by federal and state regulations. Specific review types may include case management, program payment appropriateness, program and policy compliance, billing, coding and medical record documentation reviews, as well as research and analysis of industry trends. The Medicaid Auditor III will perform audits as assigned which consist of but are not limited to performing licensing and exclusion reviews on providers and work with the medical staff to ensure services are reimbursed meet regulatory requirements. The Medicaid Auditor III will work independently as well as collaboratively with other audit staff.
Job Responsibilities:
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.
Ensures compliance with all applicable privacy and security training requirements (both IntegrityM and external/client-based), whether on an annual or ad/hoc basis. Please note: certain position levels (leads, managers, directors or higher) may require additional “role-based” training to ensure compliance with applicable privacy and security requirements.
Exercises appropriate discretion and independent judgment relating to company policies and practices in an effective, consistent and professional manner.
Adheres to applicable policies ensuring commitment to quality, compliance and security to protect the confidentiality, integrity, and availability of sensitive data and information.
Adheres to all IntegrityM and/or client privacy and security protocols governing sensitive and/or business confidential information.
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.
