Medical Program Auditor/ Analyst

University of Massachusetts Medical School•Westborough, MA

1d•Remote

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 provider types to assess compliance with federal and state regulations. Investigative work includes developing leads and detecting aberrant billing practices through data mining, claims analysis, and medical record assessment. Onsite work is required one to two times per month; all other aspects of the job are remote.

Requirements

Bachelor's degree in business, health care administration, or another related field, or an equivalent combination of education and experience.
Four to six 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, establish priorities, and work independently and collaboratively to achieve audit objectives.
Proficiency with Microsoft Office applications, including Word, Excel, PowerPoint, and Access.
Excellent customer service skills and 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 applicable to public assistance programs.

Responsibilities

Ensure compliance with federal and state regulations and healthcare FWA industry standards.
Independently mine and analyze claims data to identify patterns and trends that may indicate fraud, waste, or non-compliant billing practices.
Conduct onsite audits 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 about regulatory compliance, audit findings, and the recovery process.
Recommend policy, procedure, and system changes to improve investigative outcomes.
Regularly update appropriate internal management staff on investigation progress.
Stay current with regulatory updates, coding changes, and industry standards.
Identify trends in national fraud-related publications and recommend new or improved fraud-detection strategies.
Assist with document management, update the case-tracking system, and follow record-retention policies and procedures.
Perform other duties as assigned.