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Department

Program Integrity

Job Description

• Assesses Managed Care Entity (MCE) compliance with contract deliverables.

• Reviews and assess fraud, waste, and abuse (FWA) investigation reports, referrals, and tips from MCEs.

• Identifies and investigates audit leads and risk areas within the Medicaid program.

• Plans and performs all phases of desk and on-site reviews of provider or MCE facilities. Includes selecting an audit sample, inspecting/assessing facilities, obtaining records necessary to conduct a thorough and complete investigation, and conducting interviews with the health plan or provider and staff.

• Prepares case documents, audit summaries, and reports.

• Coordinates law enforcement requests, managed care investigations, external audit requests, referrals, tips, and complaints with MCEs, MFCU, and other Program Integrity staff.

• Maintains case lists, investigation documents, Program Integrity policies and procedures, written communications and directives sent to MCEs, and other programmatic documentation as requested.

• Recommends appropriate sanctions or corrective actions based on audit or investigation findings.

• Researches and assists with MCE contract questions; recommends contract and policy changes as needed.

• Educates providers on appropriate billing and Medicaid policy, rules, and regulations.

• Assists with data mining and other special projects at the request of LDH Program Integrity staff.

• Assists with development of reports and data dashboards to enhance MCE oversight efforts.

• Assists co-workers with questions and/or issues that arise.

• Assists with MFCU/PI/MCE meetings and communications.

• Other duties as assigned.

QUALIFICATIONS
REQUIRED:

• Bachelor’s Degree, or Associates degree with 3 years professional experience, or 6 years professional experience in lieu of degree.

• Minimum 1 year of professional experience in auditing, policy, data analysis, or claims monitoring/processing.

• Excellent analytical skills, effective organizational and time management skills.

• Great attention to detail and follow up.

• Ability to manage projects, assignments, and competing priorities.

• Proficient in the use of Microsoft Office, including but not limited to Outlook, Word, and Excel.
   

DESIRED:

• Advanced degree.

• Minimum 2 years of professional experience in auditing, policy, data analysis, or claims monitoring/processing.

• Minimum 1 year professional experience in government programs, healthcare, criminal justice, or accounting.

• Experience writing and conducting queries using SQL and/or SAS.

• CPT, ICD 10 coding and HCPCS knowledge.

• CHDA, HIM, RHIA, RHIT, CCA, CMA, CPA, CIA, CGAP, HFMA or other relevant industry certifications.

Posting Close Date

This position will remain open until filled.