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GENERAL SUMMARY OF POSITION:

Under the general direction of the Associate Director or designee, the Program Auditor serves a crucial role in combating fraud, waste and abuse (FWA) within the Medicaid program.  A major function of this position is to conduct desk and onsite reviews based on federal and state regulations that govern provider types.  Audits involve extensive research to identify industry trends and patterns in order to detect aberrant billing practices.  Working independently, or within a team, the Auditor performs all activities related to data mining, claims analysis, and auditing. The auditor will participate in face to face entrance and exit conferences with providers utilizing established interviewing skills.

MAJOR RESPONSIBILITIES:

• Apply in-depth knowledge of federal and state regulations and healthcare industry standards.
• Conduct independent data mining and data analysis utilizing claims data to identify potential cases of FWA.
• Conduct onsite audits which may include a review of the physical plant, member medical records, and employee records.
• Conduct audit entrance and exit conferences with providers as well as interview provider staff.
• Develop reports of investigative findings, compile case file documentation, calculate sanctions and overpayments, and issue findings in accordance with applicable regulations, policies and procedures.
• Document work performed and audit results based on pre-determined standards and guidelines.
• Communicate with providers regarding issues such as general regulatory compliance, audit findings, and the recovery process.
• Identify and recommend policy, procedure and system changes to enhance investigative outcomes and performance.
• Serve as a resource for internal and external departments to research and resolve integrity inquires.
• Update appropriate internal management staff regularly on progress of investigations and make recommendations for further initiatives such as new algorithms.
• Exercise independent judgment and discretion in using available resources to identify relevant evidence supporting allegations.
• Prepare internal and external reports.
• Develop, maintain and manage cases in internal case tracking system.
• Perform other duties as assigned.

REQUIRED QUALIFICATIONS:

• Bachelors degree in business administration, finance or related field; or equivalent experience
• 6-8 years of related experience in the healthcare industry, business, accounting or finance; with at least two years of experience conducting data mining in the healthcare insurance industry, healthcare claim audits or other claims related experience.
• Knowledge of the principles and practices of medical auditing.
• Strong analytical and qualitative skills as well as problem solving skills with the ability to look for root causes and implement workable solutions.
• Knowledge of the law and regulations as it relates to fraud and fraud investigations.
• Must have a track record of producing high quality work that demonstrates attention to detail.
• Ability to multi-task, establish priorities and work independently to achieve objectives.
• Ability to function effectively under pressure.
• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint and Access).
• Excellent Customer service skills with the ability to interact professionally and effectively with providers, third party payers, and staff from all departments.
• Strong Interpersonal skills with the ability to work in a fast paced environment whether as a team member or an independent contributor.
• Strong oral and written communication skills including internal and external presentations.
• Ability to travel and be on-site as needed for audits.

PREFERRED QUALIFICATIONS:

• Masters degree in Business Administration or Public Health.
• Knowledge of coding, reimbursement and claims processing policies.
• Prefer individual possessing any of the following certifications or licensure: CFE, CPA, RN/LPN, CPC, or CPMA.  
• Advanced Microsoft Excel software skills.
• Knowledge of State and federal regulations as they apply to public assistance programs.
• Strong Decision making skills with the ability to investigate and weigh alternatives and select the appropriate course of action.
• Creative thinking skills with the ability to ask the needed “bigger- picture” questions that lead to process and team improvements.