Program Integrity Auditor

About the role

The Program Integrity Auditor serves as an audit team member for health plans administering benefits to Medicaid members across various lines of business including acute, behavioral health, developmental disabilities, and out-of-home care. Responsibilities include reviewing and interpreting claims data, medical records, and documentation to ensure compliance with regulatory standards. Duties also involve identifying aberrant billing patterns, reporting potential fraud, waste, or abuse, assisting with regulatory investigations, and providing training on coding and documentation rules.

Responsibilities

• Serve as an audit team member for health plans administering benefits to Medicaid members across various lines of business.
• Review and interpret claims data, medical records, and documentation to ensure compliance with regulatory standards.
• Identify aberrant billing patterns and report potential fraud, waste, or abuse.
• Avoid, detect, and refer potential fraud, waste, or abuse to state regulators.
• Create and submit regulatory deliverables through timely audit activities.
• Provide technical assistance and education to providers regarding regulatory requirements and coding/documentation rules.
• Maintain compliance with company policies and procedures.

Requirements

• 3-5 years of experience in reviewing and interpreting claims data, medical records, and appropriate documentation.
• 3-5 years of experience with standard industry coding guidelines such as CPT, HCPCS, and ICD-10.
• An active CPC (Certified Professional Coder), CCS (Certified Coding Specialist), or CPMA (Certified Professional Medical Auditor) license.
• Previous auditing experience.
• Previous Medicaid and/or health plan experience, including AHCCCS (Arizona Health Care Cost Containment System).
• Previous experience with QuickBase.
• Strong analytical and critical thinking skills.
• Strong attention to detail.
• Ability to collaborate and work with a team, as well as work independently as needed.
• Excellent presentational and communication skills, both written and verbal.
• Ability to adapt to a flexible environment.

Qualifications

• Associate’s degree or equivalent experience (2+ years of relevant experience + high school diploma or GED).
• Willingness to work Monday-Friday from 8am-5pm Arizona Time Zone.

Benefits

This full-time position is eligible for a comprehensive benefits package including medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. The typical pay range for this role is $46,988.00 - $122,400.00, with an anticipated weekly hours of 40. The position is eligible for a CVS Health bonus, commission, or short-term incentive program in addition to the base pay range listed above.