Provider Network Auditor

Saginaw County Community Mental Health Authority•Saginaw, MI

4h•$62,729 - $77,205

About The Position

Under general supervision of the Provider Network Auditing Supervisor, responsible for conducting program audit functions for Saginaw County Community Mental Health Authority (SCCMHA) as part of a compliance and quality performance program to safeguard against fraudulent or erroneous claims of consumer service provision on behalf of SCCMHA. Working with approved regulatory and contractual guidelines and SCCMHA policies, this position will work individually or in a team to initiate, compile, complete, document and analyze audit findings for SCCMHA. Audits both contracted and board operated programs. Verifies event documentation and identifies system deficiencies by provider (i.e. billing code and modifier deficiencies). Reviews provider service delivery records and may conduct contractor compliance reviews. Presents summary information to key SCCMHA management team staff as requested or indicated. Represents SCCMHA to the provider network in monitoring and compliance measurement verbal and written communications. Required to develop in-depth knowledge of service requirements for varied SCCMHA programs. This position will be knowledgeable about and actively support culturally competent recovery based practices; person centered planning as a shared decision making process with the individual, who defines his/her life goals and is assisted in developing a unique path toward those goals; and a trauma informed culture of safety to aid consumer in the recovery process.

Requirements

Bachelor’s degree in social work, psychology, or closely related human services field and knowledge of health care administration, or a Bachelor’s in a business related area required.
A minimum of five (5) years of experience in health care, business or related financial or program field. Audit and/or data analysis experience preferred.
Business, finance and computer skills, including spread sheet functions, are required.
Valid Michigan Driver’s license with good driving record.
Analytical ability, finance, math and/or research skills, organization strengths and effective written and verbal communication skills are essential.
Computer skills are required.
Ability to exercise independent and mature judgment; diplomacy, discretion, interpersonal problem-solving and attention-to-detail abilities are required.
Ability to manage conflict and quickly shift and/or manage multiple work priorities.
Ability to represent the organization in a positive, professional manner.
Ability to provide educational support to providers on service topic and provider compliance areas.
Hearing acuity to converse in person and on telephone.
Visual Acuity to read and proofread documents and use CRT.
Ability to walk, stand or sit for extended periods of time.
Manual dexterity to write and to operate standard office equipment (PC, Keyboard, Copy Machine, Fax Machine, etc.)
Ability to lift and carry files and supplies at least 20 pounds.
Strong interpersonal skills to interact with leadership, employees, consumers and the general public.
Analytical skills necessary to conduct research, analyze, and interpret complex data and identify and solve problems by proposing courses of action.
Ability to plan short and long range and to manage and schedule time.
Ability to handle stress in meeting deadlines and dealing with large numbers of employees and/or consumers.

Nice To Haves

Human service experience and/or knowledge preferred.
A general knowledge of mental health system, and compliance or medical records experience would be helpful.
Knowledge of adult foster care licensing and other service system accreditation requirements helpful.
Demonstrated writing and presentation skills are required.

Responsibilities

Establishes audit samples, basis, schedules and plans with audit team members.
May be assigned specific program types for audit tasks based on experience or SCCMHA needs.
Contributes to audit program development; recommends modifications based on testing or use.
Conducts annual, routine or ad-hoc SCCMHA audits or provider reviews to meet organizational goals.
Identifies areas of deficiency based on audit results, and recommends corrective areas for provider network members, including causation analysis and implementation of preventative actions.
Presents audit findings to providers, including explanation and justification for negative findings and/or audit score levels.
Reviews provider corrective action plans and outcomes for compliance to audit standards and recommends SCCMHA and provider proactive steps for future compliance.
Conducts audits or performance reviews based on consistent, objective standards.
Verifies that service events occurred and are properly documented to support legitimate SCCMHA authorization of funds such as billing codes and staff credential for billing services.
May conduct contract compliance or other provider record audit reviews.
Prepares letters of event verification findings and presents data to be easily reported to MDCH for annual reporting.
Visits provider programs on-site and reviews all necessary files and documentation for audit purposes.
Establishes audit findings based on documentation and factual materials and presentations.
Interprets and exercises appropriate cautions in the interpretation of audit findings for department or management staff as well as applicable providers.
Alerts Department and SCCMHA management regarding serious, immediate findings.
Alerts the Office of Recipient Rights of any issues that might pertain to a violation of the Michigan Mental Health Code.
Prepares written audit summaries and reports.
Required to meet auditing unit performance standard.
Applies compliance, regulatory and quality improvement standards in audit functions and tasks.
Recommends policy or procedural changes as appropriate.
Exercises discretion with provider data and information, including consumer confidentiality.
Recommends audit report formats and forms for SCCMHA use.
Works with Contracts and Properties Manager to coordinate provider demographic and performance data collection and communications.
Works with department and management leadership, including SCCMHA contract management, finance, operations, clinical services and compliance and quality areas to improve audit program and functional operations.
Stays abreast of provider documentation and organizational compliance requirement changes.
Coordinates work with recipient rights, clinical and management staff.
Maintains current knowledge of system changes that impact audit work, including SCCMHA procedures, business standards and licensing requirements.
Provide specific supports and educational services to specific providers as indicated or needed to assist with and promote provider compliance.
Actively monitors provider corrective action plans for completion; alerts supervisors of any needed sanctions.
Facilitates consumer involvement in site audits and promotes consumer involvement in provider operations.
Develops samples and other useful provider tools for site implementation to support compliance.
Provides education to staff or providers either one-on-one or in a group setting to clarify audit standards.
Adheres to the mission, vision, core values and operating principles of SCCMHA at all times.