Program Integrity (MCU) - Coordinator 2

University of New Orleans•Baton Rouge, LA

42d

About The Position

Assesses Managed Care Entity (MCE) compliance with contract deliverables. Reviews and assess fraud, waste, and abuse (FWA) investigation reports, referrals, and tips from MCEs. Identifies and investigates audit leads and risk areas within the Medicaid program. Plans and performs all phases of desk and on-site reviews of provider or MCE facilities. Includes selecting an audit sample, inspecting/assessing facilities, obtaining records necessary to conduct a thorough and complete investigation, and conducting interviews with the health plan or provider and staff. Prepares case documents, audit summaries, and reports. Coordinates law enforcement requests, managed care investigations, external audit requests, referrals, tips, and complaints with MCEs, MFCU, and other Program Integrity staff. Maintains case lists, investigation documents, Program Integrity policies and procedures, written communications and directives sent to MCEs, and other programmatic documentation as requested. Recommends appropriate sanctions or corrective actions based on audit or investigation findings. Researches and assists with MCE contract questions; recommends contract and policy changes as needed. Educates providers on appropriate billing and Medicaid policy, rules, and regulations. Assists with data mining and other special projects at the request of LDH Program Integrity staff. Assists with development of reports and data dashboards to enhance MCE oversight efforts. Assists co-workers with questions and/or issues that arise. Assists with MFCU/PI/MCE meetings and communications. Other duties as assigned.

Requirements

Bachelor’s Degree, or Associates degree with 3 years professional experience, or 6 years professional experience in lieu of degree.
Minimum 1 year of professional experience in auditing, policy, data analysis, or claims monitoring/processing.
Excellent analytical skills, effective organizational and time management skills.
Great attention to detail and follow up.
Ability to manage projects, assignments, and competing priorities.
Proficient in the use of Microsoft Office, including but not limited to Outlook, Word, and Excel.

Nice To Haves

Advanced degree.
Minimum 2 years of professional experience in auditing, policy, data analysis, or claims monitoring/processing.
Minimum 1 year professional experience in government programs, healthcare, criminal justice, or accounting.
Experience writing and conducting queries using SQL and/or SAS.
CPT, ICD 10 coding and HCPCS knowledge.
CHDA, HIM, RHIA, RHIT, CCA, CMA, CPA, CIA, CGAP, HFMA or other relevant industry certifications.

Responsibilities

Assesses Managed Care Entity (MCE) compliance with contract deliverables.
Reviews and assess fraud, waste, and abuse (FWA) investigation reports, referrals, and tips from MCEs.
Identifies and investigates audit leads and risk areas within the Medicaid program.
Plans and performs all phases of desk and on-site reviews of provider or MCE facilities.
Includes selecting an audit sample, inspecting/assessing facilities, obtaining records necessary to conduct a thorough and complete investigation, and conducting interviews with the health plan or provider and staff.
Prepares case documents, audit summaries, and reports.
Coordinates law enforcement requests, managed care investigations, external audit requests, referrals, tips, and complaints with MCEs, MFCU, and other Program Integrity staff.
Maintains case lists, investigation documents, Program Integrity policies and procedures, written communications and directives sent to MCEs, and other programmatic documentation as requested.
Recommends appropriate sanctions or corrective actions based on audit or investigation findings.
Researches and assists with MCE contract questions; recommends contract and policy changes as needed.
Educates providers on appropriate billing and Medicaid policy, rules, and regulations.
Assists with data mining and other special projects at the request of LDH Program Integrity staff.
Assists with development of reports and data dashboards to enhance MCE oversight efforts.
Assists co-workers with questions and/or issues that arise.
Assists with MFCU/PI/MCE meetings and communications.
Other duties as assigned.