Medicaid Program Integrity Senior Consultant

BerryDunn • Kapolei, HI

15h • $85,000 - $100,000 • Hybrid

About The Position

BerryDunn is seeking a Senior Consultant with subject matter expertise in Medicaid program integrity and claims audits to support Hawaiʻi Med-QUEST's (MQD) Medicaid Program Integrity initiatives as a forensic analyst. You will perform claims audits, document findings, and conduct forensic reviews and investigations related to Medicaid medical, dental, behavioral health, pharmacy claims, as well as provider, member, financial, and operational data. You will work as part of the BerryDunn Program Integrity team, and work closely with 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. Travel expectations: 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 three (3) years of experience conducting Medicaid claims audits, investigations, and/or compliance reviews.
• Knowledge of Medicaid Program Integrity principles, FWA, provider oversight, payment integrity, TPL, claims audit, or cost avoidance concepts.
• Experience developing or supporting 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 using 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 preferred.
• 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 fraud risk assessments, TPL, PERM, payment integrity, and public sector health program analytics.
• Experience reviewing or auditing a wide range of claims, including Medicaid medical, dental, behavioral health, and pharmacy.
• Experience coordinating across client stakeholders, vendor partners, project leadership, and cross-functional workstreams in a public sector or health and human services environment.
• Preference will be given to candidates with 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 are also considered.
• Experience with Jira, SQL, Power BI, Tableau, or comparable analytics and dashboarding tools for claims analysis, dashboard creation, and presentation.

Responsibilities

• Conduct detailed reviews of Medicaid claims and related provider, member, eligibility, financial, and operational data to identify, document, and escalate potential fraud, waste, abuse, improper payments, compliance issues, and operational risks.
• Review Medicaid claims for accuracy, compliance, reasonableness, and alignment with Medicaid policies, federal and state regulations, program requirements, and coding standards and guidance.
• Support the review of operational data related to provider management, member services, financial management, and TPL.
• Prepare audit and investigative documentation such as case summaries, findings, recommendations, workpapers, and supporting materials for review by the Forensic Manager, Program Integrity staff, audit SMEs, and project leadership.
• Research, interpret, and apply Medicaid policies, program integrity requirements, and applicable regulations to support audit findings, investigative documentation, recommendations, and corrective action follow-up.
• Assist with development of controls, monitoring approaches, review protocols, audit tools, documentation standards, and process improvements to strengthen FWA detection and deterrence.
• Support development or updates to policies, procedures related to Medicaid program integrity.
• Assist in the development of training, knowledge transfer, and technical assistance for client staff related to program integrity.
• Use Jira, SharePoint, meeting notes, decision logs, and action item trackers to support transparent issue tracking, documentation, coordination, and follow-through across workstreams.
• Support onsite planning, workgroup sessions, client leadership preparation, release activities, and related project needs in coordination with the Forensic Manager, project leadership, and workstream leads.

Benefits

• Eligible employees have access to benefits that go beyond what’s expected to support their physical, mental, career, social, and financial well-being.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree