Medicaid Program Integrity Analyst

BerryDunn•Kapolei, HI

5d•Hybrid

About The Position

BerryDunn is seeking a Medicaid Program Integrity Analyst to support Hawaiʻi Med-QUEST's (MQD) Third Party Liability (TPL) Unit and Program Integrity activities. This role will support Medicaid program integrity activities related to fraud, waste, and abuse prevention; provider oversight; compliance monitoring; risk assessment; external audit coordination; recovery efforts; and Medicaid medical, dental, behavioral health, and pharmacy claims audits. In this role, the Medicaid Program Integrity Specialist will work closely with Program Integrity staff, TPL experts, forensic specialists, data analysts, compliance SMEs, integrated IT, operations, and policy workstream members, vendor partners, and project leadership to translate Medicaid policy, program needs, claims analytics, and audit findings into practical monitoring approaches, review priorities, system requirements, change requests, operational recommendations, corrective action supports, and process improvement considerations. This individual will support dashboards, reporting, documentation quality, issue escalation, knowledge transfer, quality assurance, and ongoing improvement of payment integrity activities.

Requirements

Strong leadership, communication, facilitation, organization, and attention to detail.
Knowledge of Medicaid program integrity, fraud, waste, and abuse prevention, provider oversight, claims review, audit support, compliance monitoring, or related public sector healthcare operations.
Knowledge of quality assurance/control procedures, corrective action tracking, and proactive problem management.
Demonstrated ability to work effectively in a team setting and coordinate across multiple stakeholders, including clients, vendors, project leadership, and internal teams.
Experience coordinating recurring meetings, documenting follow-up items, maintaining workstream alignment, and supporting escalation pathways.
Strong experience with Microsoft applications and artificial intelligence tools.
Bachelor’s degree preferred; applicable experience may be considered in lieu of degree requirements.
Experience using Jira, SharePoint, Microsoft Teams, Outlook, Excel, Power BI, Tableau, SQL, or comparable tools to manage action items, documentation, reporting, follow-up, and project coordination.
Minimum three (3) years of experience in a comparable analytics, payment integrity, program integrity, claims audit, Medicaid operations, healthcare compliance, or consulting role preferred.

Nice To Haves

Prior consulting experience in a national or regional consulting firm, health plan, Medicaid agency, program integrity unit, or public sector health and human services environment.
Experience with government agencies, Medicaid program integrity units, fraud risk assessments, internal audits, external audits, claims audit reviews, quality assurance, corrective action planning, or improper payment prevention efforts.
Bachelor's Degree (BA/BS)—may substitute four years of applicable experience for the degree.
Preference may be given to candidates with certifications such as Certified Professional Coder, Certified Fraud Examiner, Certified Professional Medical Auditor, Certified Internal Auditor, or equivalent credentials.

Responsibilities

Support development of recommendations for cost avoidance, recovery, improved program controls, policy clarification, process improvement, system edits, vendor follow-up, and corrective action planning based on claims analytics and program integrity findings.
Research, interpret, and apply Medicaid payment policy, program integrity requirements, audit findings, federal and state requirements, managed care contract expectations, provider billing guidance, and operational procedures to support defensible review conclusions and recommendations.
Document and report claims audit findings, payment integrity observations, risk indicators, analytical results, and recommended actions clearly and consistently for management, client stakeholders, vendors, and project leadership.
Support training, technical assistance, workgroup facilitation, release readiness, go-live support, and knowledge transfer related to payment integrity analytics, review processes, dashboard use, documentation expectations, and follow-up procedures.
Provide quality assurance reviews of work completed by peers, including claims audit documentation, analytical findings, review protocols, reports, corrective action supports, and client-facing deliverables.
Use Jira, SharePoint, meeting notes, decision logs, action item trackers, dashboards, and reporting tools to support transparent issue tracking, documentation, coordination, and follow-through across our workstreams.
Support onsite planning, release activities, operational readiness, and related project needs in coordination with project leadership and workstream leads.
Use the following key tools and systems: Microsoft Excel, and analytics and dashboarding tools for claims analysis, payment integrity monitoring, validation, visualization, and reporting.
Use Jira for action items, risks, blockers, dependencies, audit follow-up, corrective action tracking, dashboard visibility, release readiness, and project coordination.
Use SharePoint for project documentation, report templates, payment integrity methodology, review protocols, version control, quality review, training materials, and knowledge management.
Use Microsoft Teams and Outlook for meeting coordination, stakeholder communication, workgroup facilitation, audit follow-up, training support, and client/vendor collaboration.