Auditor 3

Georgia Department of Revenue•Atlanta, GA

2d•$53,311 - $73,677

About The Position

The Auditor 3 works for the Georgia Department of Community Health, conducting medical reviews and audits related to the State Health Benefit Plan (SHBP). The role ensures reviews comply with Office of Audits guidelines, SHBP policies, and applicable state, federal, and other regulatory requirements. It evaluates nursing standards and protocols, applies medical coding principles, and supports quality improvement and compliance activities. The position coordinates with agency divisions, contracted vendors, staff, and internal and external stakeholders to monitor and mitigate fraud, waste, and abuse. It monitors vendor Special Investigation Unit activities, coordinates provider-site utilization-review visits, analyzes claims data for aberrant billing, and collaborates with audit leadership to detect, prevent, and investigate provider misconduct. The role also leads special projects and participates in audits intended to ensure claims payment integrity. Audit work includes planning and scoping engagements, conducting risk assessments, selecting appropriate methodologies, reviewing financial statements, budgetary compliance reports and claims data, and evaluating internal controls through interviews and walkthroughs. The Auditor 3 prepares organized and accurate work papers, narratives, conclusions, manuscripts, and reports in accordance with applicable professional standards and Department policies and procedures. The role also contributes to long-range planning and performs other duties as assigned.

Requirements

High school diploma or GED and four years of job-related experience, or two years of experience at the lower-level Complnc Specialist 2 (RCP061) or an equivalent position.
Some positions may require certification or licensure.
Some positions may require a valid driver's license.

Nice To Haves

Knowledge of the administration and organization of nursing services.
Knowledge of professional nursing theory, procedures, and techniques.
Knowledge of state and federal laws and regulations governing nursing practice and the provision of health care to clients.
Ability to interpret policy.
Team-oriented, self-starting, and results-driven approach.
Ability to solve problems, identify solutions, and work independently or as part of a team.
Master's degree in Nursing, Psychology, Healthcare Administration, or a similar clinical program.
Certified Fraud Examiner or Accredited Health Care Fraud Examiner credential.
Experience monitoring, investigating, and case-managing health care programs, including identifying and reviewing claims and auditing programs.
Experience preparing, reviewing, and delivering formal medical or investigative reports, including statistical summaries and qualitative analysis of findings.
Knowledge of statistical data and reporting.
Accounting- or business-related degree.
Strong governmental accounting and auditing skills.

Responsibilities

Conduct medical reviews consistent with Office of Audits guidelines and SHBP policies.
Evaluate nursing standards and nurse protocols for medical reviews.
Apply coding principles in accordance with the American Medical Association, National Center for Health Statistics, and World Health Organization.
Review state, federal, and other regulatory standards to guide quality improvement and compliance activities.
Coordinate with agency divisions to monitor fraud, waste, and abuse.
Collaborate with contracted vendors and staff to ensure SHBP providers follow plan policies and procedures and applicable state and federal laws.
Track and monitor monthly and quarterly reports concerning vendors' Special Investigation Unit activities identified in contracts.
Participate in planning, coordinating, developing, and implementing long-range goals and objectives for the Office of Inspector General.
Coordinate provider-site visits to facilitate utilization reviews.
Communicate with internal and external stakeholders at monthly meetings to mitigate fraud, waste, and abuse in the SHBP.
Lead special projects and participate in audits to ensure payment integrity of claims billed to the SHBP.
Analyze claims data to identify aberrant billing trends among providers enrolled in the SHBP.
Collaborate with the Audit Supervisor and Director to detect, prevent, and investigate provider fraud, waste, and abuse.
Conduct performance, operational, financial, and/or compliance audit projects.
Perform risk assessments and scope audit engagements.
Prepare clear, concise, accurate, and well-organized working papers in accordance with applicable standards and Department policies and procedures.
Plan projects logically and reasonably and ensure effective use of resources.
Establish audit methodologies based on audit objectives.
Analyze audit documentation, including financial statements, budgetary compliance reports, and claims data.
Conduct interviews and walkthroughs to help evaluate internal controls.
Write narratives and conclusions based on audit findings.
Organize audit work according to policies and procedures.
Assist with and prepare manuscripts and reports.
Communicate audit and compliance information, including results and conclusions, in accordance with professional standards and Department policies and procedures.
Perform other duties as assigned.