Program Integrity Audit and Investigation Analyst

Cheyenne, WY - USA

Monthly Salary: Not Disclosed

Posted on: Yesterday

Vacancies: 1 Vacancy

Job Summary

Description and Functions

Open Until Filled

GENERAL DESCRIPTION:

Responsible for completing Audit and Investigation functions to support the successful delivery of Program Integrity (PI) goals and initiatives to minimize fraud waste and abuse in the State Medicaid system. To include: reviewing utilization for the Wyoming Medicaid Program imposing appropriate adverse actions against providers identifying compliance issues and coordinating with law enforcement partners to ensure appropriate outcomes.

Working for the State of Wyoming offers more than a paycheck. Our total compensation package includes:

Comprehensive health dental and vision insurance
Paid vacation sick leave FMLA and holidays
Retirement - Pension and 457B plans that help you build a secure future
Flexible schedules and work-life balance options
Meaningful work that makes a difference for Wyoming communities

and MUCH MORE!Click here for detailed information or you can watch this short video to learn about our benefit package!

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Human Resource Contact:

ESSENTIAL FUNCTIONS: The listed functions are illustrative only and are not intended to describe every function that may be performed in the job level.

Complete Audit and Investigative Functions:

Plan and conduct independent audits and investigations of Wyoming Medicaid State Plan and Waiver providers utilizing appropriate data analysis resources and tools. Review complex audit and investigation documentation perform audit and investigation duties and make remediation and corrective action plans based on audit or investigation findings. Make independent recommendations for the initiation of overpayment recovery actions based on audit or investigative findings. Collaborate with law enforcement and Attorney General staff to testify on findings at contested case hearings and civil or criminal legal proceedings. Make recommendations and identify areas requiring further investigation to the Audits and Investigations Supervisor.

Establish and Execute Audit Plans:

Plan and conduct independent audits and investigations of Wyoming Medicaid State Plan and Waiver providers utilizing appropriate data analysis resources and tools. Review complex audit and investigation documentation perform audit and investigation duties and make remediation and corrective action plans based on audit or investigation findings. Make independent recommendations for the initiation of overpayment recovery actions based on audit or investigative findings. Collaborate with law enforcement and Attorney General staff to testify on findings at contested case hearings and civil or criminal legal proceedings. Make recommendations and identify areas requiring further investigation to the Audits and Investigations Supervisor.

Coordinate Activities for Unified Program Integrity Contractor (UPIC):

Coordinate efforts and act as the primary point of contact for the Unified Program Integrity Contractor. Coordinate referrals to the Unified Program Integrity Contractor (UPIC) and act as the primary point of contact for the federal UPIC attending meetings reporting on the ongoing status of referrals made and coordinating the fulfillment of documentation requests. Update case file documentation to the PI case management system. Monitor ongoing status and outcome after referral.

Post-Audit Monitoring Process:

Oversee the monitoring of provider post-audit compliance as outlined in the audit findings and corrective action plan. Set protocols and oversee implementation of provider self-audits and self-reporting. Draft procedure and policy related to the education of providers notification of requirements timelines and findings. Facilitate and monitor the development implementation and execution of provider quality improvement plans. Direct validation of findings and written reports. Communicate recommendations to programs and management.

Qualifications

PREFERENCES:

Preference may be given to candidates with a Bachelors degree in a related fieldsuch as Human Services Accounting Statistics or Criminal Justiceand 13 years of progressive experience in auditing investigations data analytics or compliance analysis.

Alternatively we are looking for individuals with a degree and background that demonstrate the analytical and investigative skills necessary to perform quality assurance and investigative techniques.

KNOWLEDGE:

Knowledge of healthcare delivery and regulatory systems at both the State and Federal levels and integrated automated systems currently used by the Division of Healthcare Financing.
Knowledge of medical terminology medical diagnostic and procedural terms and common medical payment procedural codes used in Current Procedural Terminology (CPT) and other nationally recognized coding references.
Knowledge of court proceedings testimony and administrative appeals.
Knowledge of state and federal government functions state and federal statutes rules regulations policies and procedures governing Federal and State Medicaid and Medicare programs.
Knowledge of Medicaid law and regulatory structure including State and Federal Medicaid statutes regulations and policies as outlined in the Code of Federal Regulations.
Knowledge of fraud and abuse detection methods internal control systems.
Skills in research and analysis of complex problems; identification of options and solutions; decision making and evaluation of results.
Skills in public speaking oral and written communication to varied audiences on complex and controversial issues.
Ability to establish and maintain positive working relationships with individuals and groups.
Ability to accept and be flexible with federal state and agency changes.
Ability to balance multiple demands on time and resources.
Ability to self-educate both formally and informally to remain current in areas of responsibility.
Skill in operating computer equipment and software programs including Microsoft Excel PowerPoint SharePoint Word COGNOS Business Intelligence Tools BMS and case management systems.
Skill in active listening creative problem-solving skills; strong oral written and interpersonal communication skills at a variety of levels and with multiple audiences.
Skill in critical thinking with an ability to evaluate complex sets of data and information to determine whether aberrancies patterns or discrepancies exist.
Skill in establishing and maintaining effective working relationships with other program managers providers and the public.
Ability to work independently with minimal supervision while balancing multiple demands on time and resources.
Ability to utilize sound judgment in decision making and formulate concise answers and plans with known information while interpreting DHCF rules policies and procedures.
Ability to analyze and comprehend complex Medicaid service utilization provider enrollment and client eligibility data; identify patterns trends problems and solutions; leverage deductive reasoning skills to form sound conclusions.
Ability to draft concise reports utilizing technical writing tools and techniques.
Experience demonstrating the ability to collect and organize information from complex data systems.
Experience in decision making and evaluation of results to make future program recommendations based on trends; Experience gathering and compiling data to meet Program Integrity user needs through the use of tables charts graphs and written reports.
Must be detail-oriented highly organized and self-motivated.
Must maintain a high level of confidentiality both inside and outside of DHCF.

MINIMUM QUALIFICATIONS:

Education:

Bachelors Degree (typically in Records or Data Management)

Experience:

0-3 years of progressive work experience in (typically in Records and Data Management) with acquired knowledge at the level of a Records & Data Management Specialist II

Education & ExperienceSubstitution:

4-6 years of progressive work experience in (typically in Records and Data Management) with acquired knowledge at the level of a Records & Data Management Specialist II

Certificates Licenses Registrations:

None

Necessary Special Requirements

PHYSICAL WORKING CONDITIONS:

This position takes place in an average work environment.

NOTES:

FLSA: Exempt
The Wyoming Department of Health is an E-VerifyEmployer.

Supplemental Information

Clickhereto view the State of Wyoming Total Compensation Calculator.

Click here to view the State of Wyoming Classification and Pay Structure.

URL: State of Wyoming is an Equal Opportunity Employer and actively supports the ADA and reasonably accommodates qualified applicants with disabilities.

Class Specifications are subject to change please refer to the A & I HRD Website to ensure that you have the most recent version.

Required Experience:

Description and FunctionsOpen Until FilledGENERAL DESCRIPTION: Responsible for completing Audit and Investigation functions to support the successful delivery of Program Integrity (PI) goals and initiatives to minimize fraud waste and abuse in the State Medicaid system. To include: reviewing utiliza...