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Medicaid Audit and Compliance Specialist (Full-time, Remote)

1 day, 1 hour ago
United States
Full-time
Senior
Compliance Manager
Finance and Accounting
Apply Now
IntegrityM

IntegrityM

Integrity Management Services Offers a large variety of data integrity solutions including audits, fraud investigations, medical reviews, and more. Certified #WOSB providing expertise in #analytics, #audits #investigations #compliance #medicalreview #s...

Professional Services
51-250
Founded 2009
View All Jobs 2

Description

  • Perform audits of Medicaid Managed Care Plans and providers to identify potential fraud, waste, and abuse, and calculate improper payments.
  • Conduct programmatic and financial audit assignments, including desk reviews and onsite reviews covering case management, payment appropriateness, policy compliance, billing/coding, and medical record documentation.
  • Apply federal and state regulations, contract-specific auditing plans, and Generally Accepted Government Auditing Standards (GAGAS) to interpret laws, policies, and audit methodologies.
  • Utilize data mining and trend analysis tools to detect anomalies in Medicaid billing and payment patterns.
  • Perform licensing and exclusion reviews on providers and coordinate with medical staff to ensure services meet regulatory requirements.
  • Prepare and submit medical record request letters, attend on-site audits, conduct provider entrance/exit conferences, and issue suspension overpayment determinations when applicable.
  • Prepare factual, objective written audit and investigative reports in conformance with professional standards and present findings to leadership, external agencies, and government partners.
  • Maintain and update case development databases and documentation, develop investigative case files, and ensure quality standards for fraud case development.
  • Communicate with federal/state agencies and providers regarding regulatory compliance, audit findings, corrective actions, and recovery processes, and identify process weaknesses with recommendations for improvements.

Requirements

  • Bachelor’s degree in finance, accounting, or a related field (required).
  • 5–7 years of related experience in finance, accounting, or auditing.
  • Intermediate knowledge of internal audit policies, operating principles, and application of government accounting principles.
  • Experience auditing Medicare/Medicaid and other government payment and oversight programs (e.g., CMS, HRSA, OIG, DOE, Dept. of Commerce).
  • Knowledge and experience applying Generally Accepted Government Auditing Standards (GAGAS).
  • Investigative experience, including developing fraud cases and maintaining case documentation.
  • Experience reviewing claims for appropriate billing and medical coding requirements, performing medical review, and calculating improper payments.
  • Strong data analysis skills and proficiency in Microsoft Office, specifically Word and Excel.
  • Knowledge of medical terminology and coding systems, including ICD-9-CM, ICD-10-CM, HCPCS Level II, and CPT codes.
  • Strong oral and written communication, interpersonal and organizational skills; ability to maintain confidentiality, multitask, meet deadlines, work independently and in a team, pass post-hire background screening, and (if remote) have wired and/or wireless internet access.

Benefits

  • Small, flexible workplace offering an exceptional quality of life.
  • Professional development opportunities and an idea-driven environment that nurtures employee growth.
  • Corporate-driven sustainability initiatives.
  • Large-company perks combined with a small-company culture and feel.
  • Remote work options available (remote work requires wired and/or wireless internet access).

Interested in this position?

Apply directly on the company website

Apply Now

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