Medicaid Auditor

About Us

Integrity Management Services, Inc. (IntegrityM) is an award-winning, women-owned small business specializing in assisting government and commercial clients in compliance and program integrity efforts, including the prevention and detection of fraud, waste and abuse in government programs. Results are achieved through data analytics, technology solutions, audit, investigation, and medical review.

At IntegrityM, we offer a culture of opportunity, recognition, collaboration, compassion and supporting our community. We thrive off of these fundamental elements that make IntegrityM a great place to work. Our small, flexible workplace offers an exceptional quality of life and promotes corporate-driven sustainability. We deliver creative solutions that exceed goals and foster a dynamic, idea-driven environment that nurtures our employees’ professional development. Large company perks…Small company feel!

Position Overview:

The Medicaid Auditor must use a variety of tools to initiate and apply sound auditing principles to Medicaid managed care investigations and audits, identify subjects and develop cases for future action, including referral to law enforcement, education, over payment recovery and other administrative actions. The Auditor compiles and analyzes financial information to record transactions, prepares reports, and reviews and verifies accuracy. The Auditor will work with internal resources and external agencies to develop cases and corrective actions as well as respond to requests for data and support.

Requirements

Minimum skills/experience for the position include:

• Bachelor’s degree in finance, accounting, or related field preferred.
• Typically 2+ years of related experience in finance, accounting, or auditing.
• Medicaid managed care work experience.
• Intermediate understanding of Medicaid managed care.
• Intermediate knowledge of internal audit policies and operating principles.
• Sufficient writing skills to write a report that clearly identifies any fraud discovered, is easily comprehended, is complete, is thorough, and is accurate and supported by sufficient documentation.
• CPA, CFE, and/or AHFI certification is a plus.
• Used Unified Case Management (UCM) and One PI Business Objects.
• Managed large/varied case loads.
• Reviewed medical claims and developing fraud cases.
• Applied company policies and procedures in relation to complex investigations.
• Reviewed financial records and advise or assist in the investigation of alleged fraud.
• Experience with statistical sampling and/or advanced statistical training.
• Knowledge of the healthcare industry and medical coding concepts (CPT, ICD-9 / 10, DRGs) and/or experience analyzing health care claims data.

Preferred skills/experience for the position include:

Essential Functions:

The Medicaid Auditor will perform audits as assigned, which consist of but are not limited to:

• Examination of all records, accounts, controls, medical billing and fiscal procedures of a Medicaid service provider.
• Use of audit techniques and procedures to verify the appropriateness of the service provider charges for Medicaid eligible clients/services.
• Maintenance of audit notes and preparation of a written report summarizing the conclusions reached during the audit.
• Preparation of exhibits such as analyses, graphs, reports, etc., intended to enhance and clarify any audit, which may be complex and hard to understand.
• Perform licensing and exclusion reviews on providers and work with the medical staff to ensure services reimbursed meet regulatory requirements.
• Conduct research on relevant State regulatory support for specific State’s and provider types.
• Review all applicable State policies and regulations associated to each specific audit assignment or algorithm prior to performing audit.
• Understand and maintain the ability to apply regulatory support to the audit findings including ensuring that the citation works for the Provider type being audited.
• Attend on-site audits to retrieve medical records and conduct provider entrance/exit conference.
• Ensure GAGAS standards are applied to each applicable audit to identify fraud, waste or abuse.
• Occasionally go into the field to collect, evaluate, and analyze evidence during an ongoing investigation.
• Occasionally be required to assist in an ongoing investigation by conducting field interviews with investigators of providers and/or beneficiaries or patients witnesses.

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