Integrity Management Services, Inc.

Medicaid Auditor III

Integrity Management Services, Inc.

full-time

Posted on:

Location Type: Remote

Location: Virginia • United States

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About the role

  • 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.
  • Ensures compliance with all applicable privacy and security training requirements (both IntegrityM and external/client-based), whether on an annual or ad/hoc basis. Please note: certain position levels (leads, managers, directors or higher) may require additional “role-based” training to ensure compliance with applicable privacy and security requirements.
  • Exercises appropriate discretion and independent judgment relating to company policies and practices in an effective, consistent and professional manner.
  • Adheres to applicable policies ensuring commitment to quality, compliance and security to protect the confidentiality, integrity, and availability of sensitive data and information.
  • Adheres to all IntegrityM and/or client privacy and security protocols governing sensitive and/or business confidential information.

Requirements

  • Bachelor’s Degree in finance, accounting or related field required.
  • 5-7 Years of related experience in finance, accounting, or auditing.
  • Intermediate knowledge of internal audit policies and operating principles.
  • Intermediate knowledge and experience in auditing Medicare/Medicaid and other government payment and oversight programs. (CMS, HRSA, OIG, DOE, Dept. of Commerce etc.)
  • Knowledge and experience in the application of government accounting principles and standards, including Generally Accepted Government Auditing Standards (GAGAS).
  • Experienced investigative skills.
  • Strong data analysis skills.
  • Knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS level II and CPT codes. Utilizes Medicaid and Contractor guidelines for coverage determinations.
  • Experience in reviewing claims for appropriate billing and medical coding requirements, performing medical review, and/or developing fraud cases.
  • Strong oral and written communication skills, strong interpersonal skills, and superior organizational abilities.
  • Ability to take initiative, to maintain confidentiality, to meet deadlines, and to work in a team environment.
  • Ability to report work activity on a timely basis.
  • Ability to work independently and as a member of a team to deliver high quality work.
  • Ability to multitask and prioritize assignments while meeting deadlines.
  • Proficiency in Microsoft Office, specifically Microsoft Word and Excel.
  • Passion and alignment with IntegrityM’s mission, vision, values and operating principles.
  • Must pass post hire background screening checks.
  • For remote work, required to have wired and/or wireless internet access.
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
data analysisauditingfinancial document examinationMedicaid billingmedical codingfraud investigationgovernment accounting principlesGAGASICD-9-CMICD-10-CM
Soft Skills
strong communication skillsinterpersonal skillsorganizational abilitiesinitiativeconfidentialityteamworkmultitaskingprioritizationindependent judgmentadherence to policies