SME - Medicaid Program Integrity and Claims Audits

BerryDunn

10h•Hybrid

About The Position

BerryDunn is seeking a Senior Consultant with subject matter expertise in Medicaid program integrity and claims audits to assist clients with prevention and detection of fraud, waste, and abuse. This individual will be responsible for assisting with risk assessment, external audit coordination, interpretation and application of Medicaid policy and applicable code of federal regulations, and conducting Medicaid medical, dental, behavioral health, and pharmacy claims audits. You will work remotely, hybrid, or in one of our offices, mainly helping client in Guam. You will report to and partner with Government Assurance Practice Group management team members for both client work and career development. With a growth mindset, you will drive your own development with support from our management team. Travel Expectations: Travel to client sites can range up to 50%.

Requirements

Excellent communication skills
Ability to conduct research and analysis related to Medicaid policies.
Medical claims billing or adjudication experience.
Strong communication skills and attention to detail.
Bachelor's Degree (BA/BS)—May substitute four years of applicable experience for degree.
Knowledgeable in quality assurance/control procedures and demonstrated proactive problem management skills.
Demonstrated ability to excel in a team setting.
Strong experience with Microsoft applications and artificial intelligence
Willingness to travel
Willingness to work flexibly to serve clients in different time zones

Nice To Haves

Prior consulting experience in a national or regional consulting firm, and experience working in/with a state Medicaid agency
Experience with government agencies, ideally working with Medicaid program integrity units
Experience with fraud risk assessments
Experience with internal audits
Certified Professional Coder (CPC) or equivalent
Certified Fraud Examiner (CFE) or equivalent
Certified Professional Medical Auditor (CPMA) or equivalent.
Certified Internal Auditor (CIA) or equivalent

Responsibilities

Establish and monitor Medicaid program integrity objectives, and key performance indicators (KPIs).
Ensure the Medicaid program integrity policies and procedures meet federal and state policies and grants compliance.
Research Medicaid policies and regulations.
Advise and assist clients in translating Medicaid policy and program needs into system requirements and change requests, ensuring the State’s program, policy, and business objectives are accurately captured using industry-standard language.
Provide frequent, clear, and consistent communication to the client, team members, and vendors.
Develop or update policies and procedures related to Medicaid program integrity.
Develop corrective action plans to solve program problems.
Analyze Medicaid program integrity reports.
Assist in the development and train the agency on program requirements.
Serve as a senior systems advisor with a strong understanding of the system implementations.
Review and audit Medicaid claims for accuracy, legality, and reasonableness
Make accurate and informed recommendations on claims based on Medicaid policies and regulations and claims data.
Document and report audit findings to management
Stay up-to-date with changes in Medicaid regulations and industry trends
Medicaid systems research and analysis, including but not limited to, member benefit groups, billing codes, system configuration, service limits, system requirements, and electronic billing standards.
Provide quality assurance reviews of work completed by peers