Program Integrity Auditor

The Program Integrity Auditor is responsible for the review of records for medical, behavioral, transportation, and other healthcare providers. The Auditor must determine correct coding and appropriate documentation during the review of medical records. Activities include reviews/audits of provider records to ensure appropriate coding standards and documentation standards are met, recommending follow-up actions such as provider education, recoupment of funds, or referral to state regulators for suspected fraud, waste, or abuse (FWA).

Responsibilities

• Serve as an audit team member for a health plan(s) administering benefits to Medicaid members across multiple lines of business, including acute, behavioral health, individuals with developmental disabilities, and children in out-of-home care.
• Audit records routinely and on an ad hoc basis to ensure coding and documentation meet regulatory standards (e.g., appropriate code usage, modifier usage, place of service).
• Coordinate audit documentation and reports for internal and external stakeholders.
• Identify aberrant billing patterns and potential FWA, reporting findings to internal staff and assisting with investigations or referrals to state regulators.
• Assist with developing and implementing plans for prospective and retrospective FWA avoidance, detection, and referral.
• Assist with the creation and submission of regulator deliverables through timely audit activities.
• Provide technical assistance and education to providers on regulatory requirements, coding, and documentation rules.
• Maintain compliance with company policies and procedures.
• Perform other duties as assigned.

Requirements

• 3-5 years of experience reviewing and interpreting claims data, medical records, and documentation.
• 3-5 years of experience with standard industry coding guidelines (CPT, HCPCs, ICD-10).
• Active CPC (Certified Professional Coder), CCS (Certified Coding Specialist), or CPMA (Certified Professional Medical Auditor) license.
• Willingness to work Monday-Friday from 8am-5pm Arizona Time Zone.

Qualifications

Associate's degree or equivalent experience (2+ years of relevant experience + high school diploma or GED).

• 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 in a team or work independently as needed.
• Excellent presentational, written, and verbal communication skills.
• Adaptability in a flexible environment.

Pay

The typical pay range for this role is $46,988.00 - $122,400.00 annually. This position is also eligible for a CVS Health bonus, commission, or short-term incentive program in addition to base pay.

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.

Schedule

• Full time (40 hours per week).