Senior Medicaid Auditor

Summary

Join Integrity Management Services, Inc. (IntegrityM) as a Senior Auditor and contribute to our mission of assisting government and commercial clients in compliance and program integrity efforts. You will perform and report on Medicaid Managed Care Plans to identify potential fraud, waste, and abuse, issuing findings and recommendations, and identifying improper payments. Audit assignments will vary, including desk reviews and on-site activities. You will work independently and collaboratively with other audit staff, applying your expertise in federal and state Medicaid regulations, healthcare industry standards, and auditing methodologies. This role requires strong analytical, communication, and investigative skills, along with experience in medical record review and fraud case development. The ideal candidate will have a passion for IntegrityM's mission and a commitment to quality and compliance.

Requirements

• Bachelor’s degree in finance, accounting or related field preferred
• 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)
• 5+ Years of experience that is directly related to the duties and responsibilities specified
• Ability to provide guidance and training to professional staff in area of expertise
• Strong investigative skills
• Advanced 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
• Passion and alignment with IntegrityM’s mission, vision, values and operating principles
• Must pass post hire background screening checks
• For remote work, required to have wired and/or wireless internet access
• Ability to obtain security clearance, if required by Client/Contract

Responsibilities

• Applies comprehensive knowledge of federal and state Medicaid regulations, healthcare industry standards, and auditing methodologies specific to contract requirements
• Plans, prioritizes, and assigns workloads to ensure compliance with task order policies and procedures
• Conducts audits by examining and calculating data from financial documents, including provider cost reports, and applies data mining and trend analysis to detect anomalies in Medicaid billing and payment patterns
• Prepares and submits medical record request letters to providers in support of audits, overpayment suspensions, or compliance investigations
• Interprets and applies relevant laws, regulations, policies, and procedures to audit findings and formulates accurate determinations
• Prepares clear, factual, and objective reports in adherence to professional auditing and evaluation standards; presents findings to internal leadership, external agencies, and government partners
• Calculates improper payments and develops findings, recommendations, and corrective actions in accordance with applicable guidelines
• Serves as a liaison with federal and state agencies and healthcare providers to address regulatory compliance issues, communicate audit outcomes, and support recovery processes
• Applies in-depth knowledge of federal and state Medicaid 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
• 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
• 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
• 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
• Provides subject matter support to projects and/or team leadership where appropriate to other auditors
• Provides mentoring responsibilities, such as guidance, coaching and development support for to other audit staff
• Examines financial documents and statements such as provider cost reports as a method of audit
• 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