Medicaid Payment Integrity SME

BerryDunn•Kapolei, HI

3d•Hybrid

About The Position

BerryDunn is seeking an experienced Senior Consultant with subject matter expertise in Medicaid payment integrity to support Hawaiʻi Med-QUEST's (MQD) Fraud, Waste, and Abuse (FWA), program integrity, audit, third party liability (TPL), payment integrity, and claims review initiatives. You will manage forensic review, investigative, and claims audit activities related to Medicaid medical, dental, behavioral health, pharmacy, provider, member, financial, and operational data. You will provide oversight and management of day-to-day operation of program integrity activities including claims audits, forensic reviews, investigations, documentation of findings, case tracking, and corrective action follow-up. You will work as a part of the BerryDunn Program Integrity team, and work closely with the MQD Program Integrity staff, audit and TPL specialists, data analysts, compliance staff, vendor partners, and other workstream members to help identify risks, interpret policy, improve internal controls, escalate issues for leadership, and support recovery efforts. This position offers flexibility in work location, including fully onsite, hybrid, or remote arrangements. The preferred location is Kapolei, Hawaiʻi, or the U.S. West Coast. Regardless of location, the role requires availability during Hawaii Standard Time (HST) working hours. This role requires travel approximately 30%–50% of the time, including travel to Hawaiʻi for onsite client meetings, release activities, training support, go-live readiness, and related project needs.

Requirements

Minimum five (5) years of experience leading Medicaid payment/program integrity initiatives and managing provider audits, overpayment identification, claims audits, and recovery activities.
In-depth understanding of medical coding (ICD-10, CPT), claims processing, and Medicaid requirements.
Experience reviewing or auditing Medicaid medical, dental, behavioral health, pharmacy, provider, member, eligibility, TPL, or claims data.
Experience managing forensic reviews, investigations, claims audits, or compliance reviews.
Knowledge of Medicaid fee-for-service and managed care delivery systems, including managed care organization operations, claims processing, encounter data, provider network management, and payment methodologies.
Extensive knowledge of Medicaid Program Integrity, FWA, provider oversight, payment integrity, TPL, claims audit, or cost avoidance concepts.
Experience developing audit findings, corrective action plans, executive-ready reporting, analytical summaries, methodology documentation, quality checks, or recurring performance reports.
Strong analytical, documentation, quality assurance, and stakeholder coordination skills.
Experience with public sector health or healthcare compliance projects preferred.
Experience coordinating across client stakeholders, vendor partners, project leadership, and cross-functional workstreams in a public sector or health and human services environment.
Experience using Jira, SharePoint, Microsoft Teams, Outlook, Excel, or comparable tools to manage action items, documentation, investigative follow-up, and project coordination.
Bachelor's degree or equivalent combination of education and applicable experience.
Ability to conduct research and analysis related to Medicaid policies, claims, provider oversight, payment integrity, and program integrity requirements.
Ability to handle sensitive program, operational, provider, member, client, PII/PHI, and HIPAA-related information in alignment with confidentiality and data security expectations.

Nice To Haves

Experience supporting Medicaid Program Integrity, fraud risk assessments, TPL, PERM, payment integrity, claims audit, compliance monitoring, internal audit, or public sector health program analytics.
Experience with Medicaid managed care operations, including encounter data validation, capitation payment oversight, provider network requirements, and managed care program integrity activities.
Relevant certifications, such as Certified Professional Coder (CPC), Certified in Healthcare Compliance (CHC), Certified Professional Medical Auditor (CPMA).
Audit and investigation related certification such as Certified Fraud Examiner (CFE), Certified Internal Auditor (CIA), or equivalent credentials.

Responsibilities

Manage forensic review, investigative, and provider audit activities related to Medicaid medical, dental, behavioral health, pharmacy claims, as well as provider, member, financial, audit, TPL, and operational data.
Provide oversight, quality assurance, and coordination for forensic analysts, audit SMEs, claims review resources, and related team members.
Lead identification, documentation, and escalation of potential fraud, waste, abuse, or non-compliance risks.
Review Medicaid claims and medical records for accuracy, reasonableness, and compliance with Medicaid policies, federal and state regulations, program requirements, and claims data.
Research, interpret, and apply Medicaid policies, program integrity requirements, and applicable regulations to support audit findings, investigative recommendations, and corrective action planning.
Establish, monitor, and report on program integrity, claims audit, investigative, corrective action, and operational improvement objectives, metrics, and key performance indicators.
Develop and review investigative documentation, case summaries, findings, and recommendations.
Support development of controls, monitoring approaches, and process improvements to strengthen FWA detection and deterrence.
Develop corrective action recommendations and follow-up plans to address identified fraud, waste, abuse, improper payment, compliance, claims, audit, payment, or operational issues.
Assist developing or updating relevant policies and procedures.
Develop and update review protocols, audit tools, documentation standards, and training supports related to Medicaid Program Integrity, claims audits, FWA monitoring, and TPL activities.
Advise on how Medicaid policy, program integrity findings, audit results, and operational needs may translate into system requirements, change requests, process updates, or vendor follow-up.
Support training, knowledge transfer, and technical assistance for client staff related to program integrity, claims audit processes, documentation expectations, and follow-up procedures.
Support onsite planning, workgroup sessions, client leadership preparation, release activities, and related project needs in coordination with project leadership and workstream leads.