Medical Program Auditor/ Analyst

University of Massachusetts Medical School•Westborough, MA

1d•$80,000 - $95,000•Hybrid

About The Position

Under the general direction of the Associate Director or designee, the Fraud, Waste, and Abuse (FWA) Auditor identifies, investigates, and helps prevent fraud, waste, and abuse in Medicaid programs. The role conducts desk and onsite audits across various provider types to assess compliance with federal and state regulations. Investigative work includes data mining, claims analysis, and medical record assessment to develop leads and detect aberrant billing practices. Onsite work is required 1–2 times per month; all other aspects of the job are remote.

Requirements

Bachelor's degree in business, health care administration, or a related field, or an equivalent combination of education and experience.
4–6 years of related experience in the healthcare industry or business, including at least two years conducting healthcare-insurance data mining, healthcare claim audits, administrative medical record reviews, or other claims-analysis-related work.
Knowledge of CPT, HCPCS, and ICD-10 coding, reimbursement, and claims-processing policies.
Strong analytical, qualitative, and problem-solving skills, including the ability to identify root causes and implement workable solutions.
Ability to interpret and apply laws and regulations related to fraud and fraud investigations.
Ability to multitask, set priorities, and work independently and collaboratively to achieve audit objectives.
Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Access.
Excellent customer service skills and the ability to interact professionally and effectively with providers, clients, and internal stakeholders across departments.
Ability to travel within Massachusetts and work onsite as needed for audits.

Nice To Haves

CPC or CPMA certification or licensure.
Knowledge of state and federal regulations as they apply to public assistance programs.

Responsibilities

Ensure compliance with federal and state regulations and healthcare FWA industry standards.
Perform independent data mining and claims data analysis to detect patterns and trends that may uncover fraud, waste, or non-compliant billing practices.
Conduct onsite audits as required to assess the completeness of medical and administrative records and compliance with applicable regulatory requirements.
Prepare detailed audit documentation and summaries of investigative findings; compile case files; and calculate sanctions and overpayments based on cited violations.
Communicate with providers regarding general regulatory compliance, audit findings, and the recovery process.
Recommend policy, procedure, and system changes to enhance investigative outcomes.
Regularly update appropriate internal management staff on investigation progress.
Stay current with regulatory updates, coding changes, and industry standards.
Identify trends from national fraud-related publications and recommend new or improved strategies to strengthen fraud-detection efforts.
Assist with document management, update the case-tracking system, and follow record-retention policies and procedures.
Perform other duties as assigned.