Integrity Management Services, Inc.

IT Support

• Lead and manage multiple audit engagements from planning through reporting and follow-up.
• Develop audit work plans, risk assessments, and testing methodologies.
• Ensure compliance with applicable federal regulations, program guidance, and Government Auditing Standards (GAGAS).
• Supervise, mentor, and evaluate audit staff.
• Review workpapers, findings, and reports for accuracy, quality, and adherence to standards.
• Communicate audit results and recommendations to senior leadership and external stakeholders.
• Identify emerging risks and recommend process improvements.
• Support continuous enhancement of audit methodologies and internal quality controls.

Managed Care Audit Manager

Analyst

• Identify and conduct investigations into known or suspected FWA with high autonomy
• Develop documentation to substantiate findings, including formal reports, graphs, audit logs, and other supporting documentation.
• Perform root cause analysis to inform future algorithmic identification of similar claims or cases and associated savings (i.e., help move identified case types from "pay-and-chase" to preventive edits and pre-payment activity)
• Participate in the development and presentation of FWA-related education for assigned Customers
• Perform coding reviews for flagged claims, to support Coding team (if applicable).

SIU Analyst – Investigator

Auditor

• **Job Title:** **Clinical Nurse Auditor – Payment Integrity**
• **Job Summary****We are seeking an experienced **Clinical Nurse Auditor** to join our **Payment Integrity** team. In this role, you will leverage your clinical expertise, medical coding proficiency, and auditing skills to identify, monitor, and analyze unusual utilization patterns and potential fraud by healthcare providers. You will conduct prepayment claims reviews, post-payment audits, and comprehensive provider record reviews to ensure accurate billing, compliance with payer regulations, and integrity in reimbursement practices. This position requires a **Registered Nurse (RN)** with coding certifications such as **CPC** (Certified Professional Coder), **CIC** (Certified Inpatient Coder), **CDI** (Clinical Documentation Improvement), or a similar credential, through **AAPC** or **AHIMA**. Knowledge of commercial insurance plans, Medicare, and Medicaid programs is essential.
• **How You Will Make an Impact **
• - **Investigations and Audits**: Conduct in-depth medical reviews through prepayment claims review and post-payment auditing to identify potential over-utilization or fraudulent activities.
• - **Tool and Policy Development**: Assist in the creation of audit tools, policies, procedures, and educational materials to enhance audit effectiveness and maintain high standards in payment integrity.
• - **Cross-Departmental Collaboration**: Serve as a liaison with service operations and other departments to provide status updates on claims reviews and coordinate actions as needed.
• - **Data Analysis and Trending**: Analyze performance data to identify patterns and trends, collaborate with service operations to address process improvements, and recommend modifications to medical policy.
• - **Fraud Detection Support**: Support fraud investigators with medical review expertise to detect and address fraudulent activities.
• - **Mentorship**: Act as a resource and mentor to other nurse auditors, supporting their professional growth and development in audit practices.

Clinical Nurse Coding Auditor, Part-time

Compliance

• Applies in-depth knowledge of federal and state regulations and healthcare industry standards.
• Comprehends and follows auditing plans and methodologies specific to contract requirements.
• Prioritization and assignment of workload, ensuring adherence to task order policies and procedures.
• 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.
• Attend on-site audits to retrieve medical records and conduct provider entrance/exit conference.
• 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.
• Preparing 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.
• Prepare and send suspension overpayment determinations to providers when applicable.
• Communicates with federal/state agencies and providers regarding issues such as general regulatory compliance, audit findings, and the recovery process.
• Attends briefings and presentations as assigned.
• Maintains fraud case development quality standards so that proper case development is ensured, and quality cases are fully prepared.
• Maintains proper and timely updates in appropriate tools and applications for their investigations. Case development databases and documents.
• Develops and documents reports of investigative findings, compiles case file documentation, calculates improper payments, and issues findings, recommendations, and corrective actions in accordance with applicable regulations, policies and procedures.
• Program research relating to federal program applications, eligibility, payments, and other program requirements.
• 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.

Managed Care Audit Manager

SIU Analyst – Investigator

Clinical Nurse Coding Auditor, Part-time

Medicaid Audit and Compliance Specialist