Overview: The Program Integrity Audit Analyst II performs evaluation and development of leads associated with performance audits of Medicaid Managed Care Plans to identify potential fraud, waste and abuse; issues finding and recommendations, and identifies improper payments.
Satisfactory completion of Background Check required
Job Summary
Seeking a full-time, remote professional to provide services to client that will exceed expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse.
Essential Duties and Responsibilities
Understanding of state Medicaid programs and managed care plan delivery systems.
Planning, coordinating, and conducting performance audits in accordance with Government Auditing Standards.
Understanding managed care encounter data and determining areas that require improved program integrity oversight.
Designing and implementing audit strategies for performing provider payment reviews and managed care plan performance audits using independent judgment to formulate a plan of action and direction in complex audit scenarios.
Work with auditors to develop audit plans clearly defining scope, steps, and tasks to achieve stated audit objectives including plans of action for audit development and information request processing.
Documenting specific findings and recommendations for improved contract compliance and process improvement; and identifying any improper payments with conclusions based on rule, policy, and billing instructions.
Developing and supporting findings that accurately report condition, criteria, cause, and effect and proposes viable recommendations for corrective actions, as applicable.
Prioritization and assignment of workload, ensuring adherence to task order policies and procedures.
Preparing factual and objective written reports in conformance with professional auditing and evaluation standards.
Ensure findings are well defined and are fully supportable and required reports are submitted according to pre-established time guidelines.
Interpret and apply pertinent laws, regulations, policies, and procedures relevant to the specific audit findings.
Conduct matrix review meetings with auditors to ensure thorough and timely completion of assigned audit tasks in accordance with task order guidelines and direction from CMS.
Prepare and submit medical record request letters to providers associated with requests for medical record requests or suspension overpayment determinations.
Serve as mentor/trainer to new Program Integrity staff.
Perform other duties as assigned by PI Audit Supervisor or the PI Manager, Deputy PI Manager, PI Project Manager, or Medicaid Operations Lead
Competencies
Excellent research and organization, prioritization, and time management skills
Excellent verbal and written communication skills
Ability to work independently with minimal supervision
Ability to multi-task in a fast-paced environment
Knowledge of statistics, data analysis techniques, and PC skills are preferred
Experience with an inventory management and reporting system preferred
Proficiency with Microsoft Word and Excel required
Education and Experience
High School Diploma or G.E.D equivalent; preference for completed college degree, technical degree related to the position (i.e. Criminal Justice, Statistics, Data Analytics, etc.
Minimum of one (1) year of experience conducting performance or compliance audits, with preference given to those who have conducted audits involving state Medicaid programs, or one (1) year of experience with an advance degree preferred
Preference given to individuals that have attained a Certified Fraud Examiner (CFE) designation
Salary/Benefits
The salary range for this role is $60K-$70K. This is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but not limited to, relevant education, qualifications, certifications, experience, skills, geographic location, performance, and business or organizational needs.
Benefits include Medical, Dental & Vision Plans
Life, LTD and STD paid by employer
401(k) with company match
Paid time off and Company paid holidays
About Us:
WCC is a small business specializing in benefit payment validations. In addition to supporting Federal Agencies with their workers compensation programs, WCC serves as a subcontractor to Prime contractors supporting the Centers for Medicare and Medicaid Services program integrity waste, fraud and abuse initiatives.
WCC is an Equal Opportunity Employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, caste, disability, veteran status, and other legally protected characteristics and maintain a drug-free workplace.
WCC, LLC
www.wccms.com
