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

2 hours, 15 minutes ago
United States
Full-time
Senior
Accountant
Operations
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 9

Description

  • Perform programmatic and financial audits of Medicaid Managed Care Plans and providers through desk reviews and onsite review activities.
  • Identify potential fraud, waste, abuse, and improper payments, and issue findings, recommendations, and corrective actions.
  • Review case management, payment appropriateness, policy compliance, billing, coding, and medical record documentation.
  • Conduct licensing and exclusion reviews on providers and work with medical staff to verify regulatory reimbursement requirements.
  • Apply federal and state regulations, healthcare industry standards, and GAGAS to audit work.
  • Examine financial documents, provider cost reports, and other data sources to calculate and analyze discrepancies.
  • Use data mining and trend analysis tools to detect anomalies in billing and payment patterns.
  • Attend onsite audits, retrieve medical records, and conduct provider entrance and exit conferences.
  • Prepare medical record request letters, suspension overpayment determinations, and factual written reports for leadership and external partners.
  • Maintain case development records, investigative documentation, and timely updates in case management tools and databases.

Requirements

  • Bachelor’s degree in finance, accounting, or a related field.
  • 5-7 years of related experience in finance, accounting, or auditing.
  • Intermediate knowledge of internal audit policies and operating principles.
  • Intermediate knowledge of Medicare/Medicaid and other government payment and oversight programs, including CMS, HRSA, OIG, DOE, and Department of Commerce programs.
  • Knowledge of government accounting principles and standards, including Generally Accepted Government Auditing Standards (GAGAS).
  • Experience with investigative work and strong data analysis skills.
  • Knowledge of medical terminology and ICD-9-CM, ICD-10-CM, HCPCS Level II, and CPT codes.
  • Experience reviewing claims for appropriate billing and medical coding requirements, performing medical review, or developing fraud cases.
  • Strong oral and written communication skills, interpersonal skills, and organizational abilities.
  • Proficiency with Microsoft Word and Excel; ability to work independently and as part of a team, multitask, prioritize, maintain confidentiality, meet deadlines, and report work activity timely.
  • Must pass post-hire background screening checks.
  • For remote work, wired and/or wireless internet access is required.

Interested in this position?

Apply directly on the company website

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