Program Integrity Auditor (HCPS/DAIO)

State of Washington • Thurston County – Olympia, WA

11h • Hybrid

About The Position

This Health Care Program Specialist functions as an auditor and helps ensure that fraud, waste, and abuse is identified and improper payments are recovered. This position offers the flexibility to create your own audit approach and focus. The Division of Audit, Integrity, and Oversight (DAIO) is responsible for providing oversight and helping ensure the integrity of our healthcare purchasing and grant activities. This includes auditing medical and other benefit providers and beneficiaries; the identification, prevention, and investigation of fraud, waste, and abuse; grant subrecipient monitoring; managed care organization contract monitoring; PEBB/SEBB monitoring; and the oversight of behavioral health and recovery spending. This position serves as an auditor in the Audit, Investigation, and Monitoring unit. It conducts research and data analysis of provider utilization profiles; and audits, reviews, and investigates Apple Health healthcare providers to identify potential fraud, waste and abuse and recover related-improper payments, and refers credible allegations of fraud and quality of care/licensing issues to the appropriate authority. Through these program integrity efforts, the position supports the HCA’s mission to “Provide high quality health care through innovative health policies and purchasing strategies.” This position is eligible to telework, however, may be required to report on-site periodically. Minimal travel may be required to attend training, conferences, or events. The default assigned work location of all Health Care Authority (HCA) positions – both on-site and telework eligible positions – is within the State of Washington. This position reports to Olympia, WA. Frequency of onsite work will vary based on business and operational needs. All agency employees are required to report on-site in Olympia on their first and last days of employment to pick up and return state-issued equipment, regardless of telework status or location.

Requirements

• Master’s degree with a major study in public health, public or business administration, auditing, or a related field. Two (2) years of experience in health services, including but not limited to direct services to clients, claims review or authorization, and business operations, or professional auditing.
• Bachelor's degree with a major study in public health, public or business administration, auditing, or a related field. Four (4) years of experience in health services, including but not limited to direct services to clients, claims review or authorization, and business operations, or professional auditing.
• Eight (8) years of experience in health services, including but not limited to direct services to clients, claims review or authorization, and business operations, or professional auditing.
• One year as a Health Care Program Consultant in State Government with duties and responsibilities in a supervisory or consultative capacity in health services, social services or Medicaid programs, including audits or reviews of healthcare claims
• The ability to take action to learn and grow.
• The ability to take action to meet the needs of others.
• Detail-oriented with the ability to understand the nuances and variables of data.
• An objective mindset and a demonstrated ability to apply sound criteria in reaching fact-based conclusions.
• Demonstration of clear, effective oral and written communication skills.
• Demonstration of the ability to gather information from a variety of resources.
• Condense content and produce comprehensive, informative reports.
• Proficient in the use of Microsoft software, including Word and Excel.

Nice To Haves

• Working knowledge of medical terminology and interpretation of health care documentation.
• Knowledge of healthcare auditing concepts and principles.
• Working experience conducting medical record reviews and ability to interpret and apply Federal and State regulations, coding and billing requirements.
• Demonstrated experience in data mining, data interpretation, and data analysis.
• Knowledge of current and developing trends in medical healthcare delivery and billing.

Responsibilities

• Plan and conduct reviews and audits of Apple Health provider claims to determine compliance with associated federal and state regulations; agency rules, policies and billing guides; and contracts or agreements.
• Use data analytics to identify risk patterns and outliers that could represent potential fraud, waste, or abuse.
• Document the audit results identifying any improper payments with conclusions based on rule, policy and billing instructions.
• Preparing professional audit reports summarizing the results.
• Represent HCA in providing expert testimony to explain and defend audit findings throughout the informal dispute process and the formal appeal process.
• Provide provider education throughout the audit process and participate in educational presentations.
• Providing technical assistance concerning the interpretation of health care policy and procedures, program analysis, and monitoring and improvement activities.
• Identify areas in the Washington Apple Health Provider Guides and other rules that could be strengthened to clarify and improve provider compliance.

Benefits

• Work life balance
• Great benefits
• Stability
• Alternative/flexible schedules
• Mobile work options
• A great total compensation and benefit package
• WA State Government Benefits
• Safe, pleasant workplace in a convenient location with restaurants, and shopping nearby.
• Free parking!

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level