Medicaid Audit and Compliance Specialist (Full-time, Remote)

Medicaid Audit and Compliance Specialist role at IntegrityM, a women-owned small business. Responsible for performing and reporting on Medicaid Managed Care Plans and providers to identify potential fraud, waste, and abuse.

Requirements

• Applies in-depth knowledge of federal and state regulations and healthcare industry standards.
• Comprehends and follows auditing plans and methodologies specific to contract requirements.
• Examines and calculates data from financial documents and statements such as provider cost reports as a method of audit.
• Utilize data mining and trend analysis tools to detect anomalies in Medicaid billing and payment patterns.
• Prepare and submit medical record request letters to providers associated with requests for medical record requests or suspension overpayment determinations.
• Interpret and apply pertinent laws, regulations, policies, and procedures relevant to the specific audit findings and provider type being audited.
• Ensure Generally Accepted Government Auditing Standards (GAGAS) standards are applied to each applicable audit to identify fraud, waste or abuse.
• Prepare factual and objective written reports in conformance with professional auditing and evaluation standards and present findings to leadership, external agencies, and government partners.
• Calculates improper payments, and issues findings, recommendations, and corrective actions in accordance with applicable regulations, policies and procedures.
• Maintains fraud case development quality standards so that proper case development is ensured, and quality cases are fully prepared.
• Conducts on-site visits and/or interviews as required for investigation.
• Identify weaknesses in current audit processes and recommend enhancements for improved efficiency and effectiveness.
• Performs ad hoc tasks/duties as assigned.