Medical Program Integrity Auditor

Responsibilities

• Ensure compliance with federal and state regulations and healthcare FWA industry standards.
• Perform independent data mining and data analysis utilizing claims data to detect patterns and trends that may uncover fraud, waste, or non-compliant billing practices.
• Conduct onsite audits as required, to assess the completeness of medical and administrative records and the compliance with applicable regulatory requirements.
• Prepare detailed audit documentation, summaries of investigative findings, compile case files, calculate sanctions and overpayments based on violations cited.
• Communicate with providers regarding issues such as general regulatory compliance, audit findings, and the recovery process.
• Recommend policy, procedure and system changes to enhance investigative outcomes.
• Update appropriate internal management staff regularly on progress of investigations.
• Stay current with regulatory updates, coding changes, and industry standards.
• Identify trends from national fraud-related publications and recommend new or improved strategies to strengthen fraud-detection efforts.
• Assist with document management, updating case-tracking system and adhering to record retention policies and procedures.
• Perform other duties as assigned.

Qualifications

• Bachelor's degree in business, health care administration, or other related field
• 4-6 years of related experience in the healthcare industry, business; with at least two years of experience conducting data mining in the healthcare insurance industry, healthcare claim audits, administrative medical record reviews or other claims analysis related experience
• Knowledge of CPT, HCPCS and ICD-10 coding, reimbursement and claims processing policies
• Strong analytical and qualitative skills as well as problem solving skills with the ability to look for root causes and implement workable solutions
• Ability to interpret and apply law and regulations as it relates to fraud and fraud investigations
• Ability to multi-task, establish priorities and work independently and collaboratively to achieve audit objectives
• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint and Access)
• Excellent Customer service skills with the ability to interact professionally and effectively with providers, clients, and internal stakeholders from all departments
• Ability to travel within Massachusetts and be on-site as needed for audits

Preferred Qualifications

• Possessing any of the following certifications or licensure: CPC or CPMA
• Knowledge of state and federal regulations as they apply to public assistance programs