Program Integrity Auditor (Full-time Hybrid, North Carolina Based)

Alliance Health•Durham, NC

2d•$69,592 - $88,729•Hybrid

About The Position

The Program Integrity Auditor provides detailed analysis, identifies improper payments, recommends corrective action, and strives to mitigate risk through provider education and support. The primary purpose of this position is to audit provider records to ensure that services meet regulatory standards. Alliance is contractually obligated to implement measures to ensure that services are provided, billed and reimbursed in accordance with rules, regulations, coverage policies, laws, and contract requirements. This is a full-time hybrid opportunity. There is no expectation of coming into the office routinely, however, the selected candidate must be available to report onsite to the Home Office for business meetings as needed. The successful candidate will also be required to travel as needed throughout Alliance catchment area and surrounding counties (including ones outside of Alliance’s catchment area) to meet with members, providers, attend court hearing, and/or other community stakeholders.

Requirements

Bachelor’s degree in health care compliance, analytics, government/public administration, auditing, security management, criminal justice, or pre-law, from an accredited College/University
three (3) years of post-degree of experience in healthcare compliance, regulatory analysis, policy development, auditing, investigations, accreditation or any equivalent combination of related training and experience.
Knowledge of the Alliance Health service benefit plans and network providers
Knowledge of Health care industry and/or Medicare/Medicaid/Behavioral Health knowledge
Knowledge of the state and federal Medicaid laws, state and federal criminal and civil fraud laws, regulations, policies, rules, guidelines, service limitations, and various Medicaid programs
Knowledge and proficiency in claims adjudication standards & procedures
A general understanding of all major MCO functions, in particular as it relates to prior authorization, utilization reviews, grievance management, provider credentialing and monitoring
High degree of integrity and confidentiality required handling information that is considered personal and confidential

Nice To Haves

Health care industry and/or Medicare/Medicaid/Behavioral Health knowledge
Certification from AHFI, CFE, CPMA, CPC, CHC, or equivalent
CLEAR Certified Investigator (Basic and Specialized)
Clinical license as an LCSW, LCMHC, LMFT, LCAS, or LPA

Responsibilities

Conduct routine and targeted post-payment and prepayment audits of Medicaid and State funded providers to ensure that services are rendered and documented in accordance with established state and federal rules, regulations, policies, and terms of provider contractual agreements with the state
Develop audit plans and tools based on the services to be audited
Request and/or collect medical records, personnel records, policies/procedures, compliance plans, and other documents from providers based on audit plans
Systematically and accurately collect, document, and store evidence
Identify inappropriate billing and improper payments
Document audit activities and findings in a detailed report
Present audit results to leadership and Compliance Committee
Attends appeal hearings to present and explain review findings
Conduct reviews of newly enrolled providers to ensure eligibility, qualifications, and/or licensure requirements are met per state and federal rules, regulations, policies, and terms of provider contractual agreements with the state
Diligently research clinical policies, administrative code, federal/state laws to assess for noncompliance
Analyze data from a variety of sources, including but not limited to claims, authorizations, enrollment, grievances, prior audits/investigations, incident reports, policies/procedures, to inform decision making
Utilize various Strategy and Healthcare Fraud Shield reports data during the audit process
Educates providers on the errors identified in the audit process
Recognize when providers can improve through technical assistance (TA) rather than formal corrective action
Recognize quality of care issues and make recommendations to appropriate entities/authorities
Document Improper Payment Charts, Statements of Deficiency, provides feedback and technical assistance to providers as needed/requested, and follows up on provider corrective action, as applicable
Prepare for and participate in provider appeal process and/or court hearings to explain and defend audit findings
Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc. may be required
Travel to meet with members, providers, stakeholders, attend court hearings etc. is required