Medicaid Auditor (Full-time, Remote)

Integrity Management Services•Alexandria, VA

17h•Remote

About The Position

The Medicaid Auditor performs and reports on Medicaid Managed Care Plans and providers to identify potential fraud, waste, and abuse; issue findings and recommendations; and identify improper payments. Audit assignments may be programmatic or financial and can include desk reviews and onsite activities, as determined by federal and state regulations. Review types may include case management, program payment appropriateness, program and policy compliance, billing, coding, medical record documentation, and analysis of industry trends. The role follows audit plans and contract requirements, examines financial data, uses data mining and trend analysis tools, applies relevant laws and standards, and prepares factual reports and case documentation. The position communicates with providers, government agencies, and leadership regarding audit findings, compliance, and recovery processes. Remote employees must have wired and/or wireless internet access and pass post-hire background screening checks.

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 and experience auditing Medicare/Medicaid and other government payment and oversight programs.
Knowledge and experience applying government accounting principles and standards, including GAGAS.
Investigative skills.
Strong data analysis skills.
Knowledge of medical terminology and ICD-9-CM, ICD-10-CM, HCPCS Level II, and CPT codes.
Ability to use Medicaid and contractor guidelines for coverage determinations.
Experience reviewing claims for appropriate billing and medical coding requirements, performing medical review, and/or developing fraud cases.
Strong oral and written communication, interpersonal, and organizational skills.
Ability to take initiative, maintain confidentiality, meet deadlines, work in a team, and report work activity promptly.
Ability to work independently and collaboratively to deliver high-quality work.
Ability to multitask and prioritize assignments while meeting deadlines.
Proficiency in Microsoft Office, specifically Word and Excel.
Passion and alignment with IntegrityM’s mission, vision, values, and operating principles.
Must pass post-hire background screening checks.
For remote work, wired and/or wireless internet access is required.

Responsibilities

Follow audit plans and methodologies specific to contract requirements.
Prioritize and assign workload while ensuring adherence to task order policies and procedures.
Examine and calculate data from financial documents and statements, including provider cost reports.
Use data mining and trend analysis tools to detect anomalies in Medicaid billing and payment patterns.
Attend onsite audits to retrieve medical records and conduct provider entrance and exit conferences.
Prepare and submit medical record request letters to providers, including requests associated with suspension overpayment determinations.
Interpret and apply relevant laws, regulations, policies, and procedures to audit findings and provider types.
Apply Generally Accepted Government Auditing Standards (GAGAS) to applicable audits to identify fraud, waste, or abuse.
Prepare factual, objective written reports in accordance with professional auditing and evaluation standards, and present findings to leadership, external agencies, and government partners.
Calculate improper payments and issue findings, recommendations, and corrective actions in accordance with applicable requirements.
Prepare and send suspension overpayment determinations to providers when applicable.
Communicate with federal and state agencies and providers regarding regulatory compliance, audit findings, and the recovery process.
Attend briefings and presentations as assigned.
Maintain fraud case development quality standards and timely updates in applicable tools and applications.
Develop case databases and documents; prepare investigative findings reports and compile case file documentation.
Review claims for appropriate billing and medical coding requirements, perform medical review, and/or develop fraud cases.