Payment Integrity Subject Matter Expert (SME)

BerryDunn•Kapolei, HI

8d•$95,000 - $120,000•Hybrid

About The Position

BerryDunn is seeking a Payment Integrity Subject Matter Expert (SME) to support Hawaiʻi Med-QUEST's Fraud, Waste, and Abuse (FWA), Program Integrity, audit, Third Party Liability (TPL), payment integrity, claims review, and improper payment prevention initiatives. This position will provide subject matter expertise in Medicaid program integrity, claims audits, risk assessment, external audit coordination, interpretation and application of Medicaid policy and applicable federal and state requirements, and development of data-driven methodologies to identify improper payments, billing anomalies, fraud risks, compliance issues, cost avoidance opportunities, and recovery opportunities across Medicaid medical, dental, behavioral health, pharmacy, provider, member, financial, and operational data. In this role, the Payment Integrity SME will work closely with Program Integrity staff, forensic specialists, audit and TPL subject matter experts, 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. The SME will support dashboards, reporting, documentation quality, issue escalation, knowledge transfer, quality assurance, and ongoing improvement of payment integrity activities. Travel expectations: This role may require travel up to 25% of the year.

Requirements

Experience with Medicaid payment integrity, claims analytics, fraud detection, program integrity, risk assessment, improper payment prevention, recovery, TPL, claims audit, external audit coordination, or cost avoidance initiatives.
Strong data analysis, dashboarding, SQL, statistical, visualization, documentation, quality assurance, and stakeholder coordination skills.
Experience researching and analyzing Medicaid policies, applicable federal and state requirements, program integrity expectations, claims data, system configuration, billing codes, benefit groups, service limits, and electronic billing standards.
Experience coordinating across client stakeholders, vendor partners, project leadership, and cross-functional workstreams in a public sector, Medicaid, health plan, healthcare compliance, or health and human services environment preferred.
Medical claims billing, adjudication, Medicaid operations, Medicaid systems, or claims audit experience, including the ability to make accurate and informed recommendations based on Medicaid policy, applicable requirements, and claims data.
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, analytics, 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.
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

Develop, refine, and apply analytics approaches to identify improper payments, billing anomalies, outliers, fraud risk indicators, cost avoidance opportunities, recovery opportunities, and program integrity risks across Medicaid medical, dental, behavioral health, pharmacy, provider, member, financial, audit, TPL, and operational data.
Support design, validation, and use of dashboards, monitoring tools, reports, review protocols, and decision-support products for payment integrity, claims audit, FWA, TPL, corrective action, and operational improvement activities.
Analyze claims, provider, member, utilization, financial, and operational data to identify high-risk services, billing patterns, provider types, program areas, documentation gaps, policy issues, and potential overpayment or cost avoidance opportunities.
Collaborate with Program Integrity, forensic, compliance, audit, TPL, Medicaid data analysts, integrated IT, policy, operations, and vendor partners to prioritize review areas, validate findings, interpret results, and coordinate follow-up activities.
Develop data-driven methodologies, business rules, review criteria, documentation standards, and repeatable monitoring approaches that support consistent payment integrity reviews, investigative referrals, audit support, and reporting.
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.
Establish, monitor, and report on Medicaid program integrity objectives, payment integrity priorities, claims audit activities, corrective action progress, operational improvement objectives, and key performance indicators.
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.
Review and audit Medicaid claims for accuracy, legality, reasonableness, medical and program policy alignment, billing code validity, service limit compliance, and consistency with claims data and applicable Medicaid requirements.
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.
Develop or update payment integrity procedures, review protocols, audit tools, monitoring guides, dashboard requirements, report templates, training materials, and knowledge transfer supports for client staff and project team members.
Advise on how payment integrity findings, Medicaid policy interpretations, audit results, and operational needs may translate into system requirements, change requests, process updates, claims edits, documentation improvements, or vendor follow-up.
Conduct Medicaid systems research and analysis, including member benefit groups, billing codes, system configuration, service limits, system requirements, electronic billing standards, adjudication logic, and other configuration or policy elements that affect payment integrity outcomes.
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, payment integrity workgroup sessions, release activities, operational readiness, and related project needs in coordination with project leadership and workstream leads.