Senior Medicaid Auditor (UPIC) (Full-time, Remote)

About Us

Integrity Management Services Inc. (IntegrityM) is an awardwinning womenowned small business specializing in assisting government and commercial clients in compliance and program integrity efforts including the prevention and detection of fraud waste and abuse in government programs. Results are achieved through data analytics technology solutions audit investigation and medical review.

At IntegrityM we offer a culture of opportunity recognition collaboration and supporting our community. We thrive off of these fundamental elements that make IntegrityM a great place to work. Our small flexible workplace offers an exceptional quality of life and promotes corporatedriven sustainability. We deliver creative solutions that exceed goals and foster a dynamic ideadriven environment that nurtures our employees professional development. Large company perksSmall company feel!

In this role the Senior (Sr.) Auditor will be responsible for performing and reporting on Medicaid Managed Care Plans to identify potential fraud waste and abuse; issue findings and recommendations; and identify improper payments. Audit assignments can be programmatic or financial and may range from desk reviews and/or onsite review activities as determined by federal and state regulations. Specific review types may include case management program payment appropriateness (grants loans etc.) program and policy compliance billing coding and medical record documentation reviews as well as research and analysis of industry trends. The Sr. Auditor will work independently as well as collaboratively with other audit staff.

Job Responsibilities:

• Applies comprehensive knowledge of federal and state Medicaid regulations healthcare industry standards and auditing methodologies specific to contract requirements.
• Plans prioritizes and assigns workloads to ensure compliance with task order policies and procedures.
• Conducts audits by examining and calculating data from financial documents including provider cost reports and applies data mining and trend analysis to detect anomalies in Medicaid billing and payment patterns.
• Prepares and submits medical record request letters to providers in support of audits overpayment suspensions or compliance investigations.
• Interprets and applies relevant laws regulations policies and procedures to audit findings and formulates accurate determinations.
• Prepares clear factual and objective reports in adherence to professional auditing and evaluation standards; presents findings to internal leadership external agencies and government partners.
• Calculates improper payments and develops findings recommendations and corrective actions in accordance with applicable guidelines.
• Serves as a liaison with federal and state agencies and healthcare providers to address regulatory compliance issues communicate audit outcomes and support recovery processes
• Applies indepth knowledge of federal and state Medicaid regulations and healthcare industry standards.
• Comprehends and follows auditing plans and methodologies specific to contract requirements.
• Prioritization and assignment of workload ensuring adherence to task order policies and procedures.
• Examines and calculates data from financial documents and statements such as provider cost reports as a method of audit.
• Utilize data mining and trend analysis tools to detect anomalies in Medicaid billing and payment patterns.
• Prepare and submit medical record request letters to providers associated with requests for medical record requests or suspension overpayment determinations.
• Interpret and apply pertinent laws regulations policies and procedures relevant to the specific audit findings.
• Preparing factual and objective written reports in conformance with professional auditing and evaluation standards and present findings to leadership external agencies and government partners.
• Calculates improper payments and issues findings recommendations and corrective actions in accordance with applicable regulations policies and procedures.
• Communicates with federal/state agencies and providers regarding issues such as general regulatory compliance audit findings and the recovery process.
• Attends briefings and presentations as assigned.
• Maintains fraud case development quality standards so that proper case development is ensured and quality cases are fully prepared.
• Maintains proper and timely updates in appropriate tools and applications for their investigations. Case development databases and documents.
• Develops and documents reports of investigative findings compiles case file documentation calculates improper payments and issues findings recommendations and corrective actions in accordance with applicable regulations policies and procedures.
• Provides subject matter support to projects and/or team leadership where appropriate to other auditors.
• Provides mentoring responsibilities such as guidance coaching and development support for to other audit staff.
• Examines financial documents and statements such as provider cost reports as a method of audit.
• Program research relating to federal program applications eligibility payments and other program requirements.
• Conducts onsite visits and/or interviews as required for investigation.
• Identify weaknesses in current audit processes and recommend enhancements for improved efficiency and effectiveness.
• Performs ad hoc tasks/duties as assigned.
• Ensures compliance with all applicable privacy and security training requirements (both IntegrityM and external/clientbased) whether on an annual or ad/hoc basis. Please note: certain position levels (leads managers directors or higher) may require additional rolebased training to ensure compliance with applicable privacy and security requirements.
• Exercises appropriate discretion and independent judgment relating to company policies and practices in an effective consistent and professional manner.
• Adheres to applicable policies ensuring commitment to quality compliance and security to protect the confidentiality integrity and availability of sensitive data and information.
• Adheres to all IntegrityM and/or client privacy and security protocols governing sensitive and/or business confidential information.