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

The Medicaid Audit and Compliance Specialist at Integrity Management Services, Inc. is responsible for performing audits on Medicaid Managed Care Plans and providers to identify fraud, waste, and abuse, and ensure compliance with federal and state regulations.

Location: Remote (US)

Responsibilities

• Apply in-depth knowledge of federal and state regulations and healthcare industry standards.
• Comprehend and follow auditing plans and methodologies specific to contract requirements.
• Prioritize and assign workload, ensuring adherence to task order policies and procedures.
• Examine and calculate data from financial documents and statements such as provider cost reports.
• 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 records 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 GAGAS standards are applied to each applicable audit to identify fraud, waste or abuse.
• Prepare factual and objective written reports in conformance with professional auditing standards and present findings to leadership, external agencies, and government partners.
• Calculate improper payments, issue findings, recommendations, and corrective actions in accordance with regulations, policies, and procedures.
• Prepare and send suspension overpayment determinations to providers when applicable.
• Communicate with federal/state agencies and providers regarding issues such as regulatory compliance, audit findings, and recovery process.
• Attend briefings and presentations as assigned.
• Maintain fraud case development quality standards and proper case development.
• Maintain updates in investigation tools and case development databases.
• Develop and document reports of investigative findings, compile case files, and issue findings, recommendations, and corrective actions.
• Conduct program research related to federal program applications, eligibility, payments, and requirements.
• Conduct on-site visits and interviews for investigations.
• Identify weaknesses in current audit processes and recommend improvements.
• Perform ad hoc tasks as assigned.

Requirements

• Bachelor’s Degree in finance, accounting or related field.
• 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).
• Knowledge and experience in government accounting principles and standards, including GAGAS.
• Experienced investigative skills.
• Strong data analysis skills.
• Knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS level II and CPT codes.
• Experience in reviewing claims for billing and coding, medical review, and fraud development.
• Strong communication and organizational skills.
• Ability to maintain confidentiality, meet deadlines, and work in a team.
• Ability to report work activity timely.
• Ability to work independently and as part of a team.
• Multitasking and prioritization skills.
• Proficiency in Microsoft Word and Excel.

Additional Information

• Must pass post-hire background screening checks.
• For remote work, must have wired and/or wireless internet access.