Medicaid Auditor (Full-time, Remote)

Overview

This role involves auditing Medicaid Managed Care Plans and providers to identify potential fraud, waste, and abuse; issue findings and recommendations; and identify improper payments. Audit assignments may be programmatic or financial and can include desk reviews and/or onsite review activities as determined by federal and state regulations.

Specific review types may include:

• Case management
• Program payment appropriateness
• Program and policy compliance
• Billing, coding, and medical record documentation reviews
• Research and analysis of industry trends

Responsibilities

• Comprehend and follow auditing plans and methodologies specific to contract requirements.
• Prioritize and assign workload, ensuring adherence to task order policies and procedures.
• Examine and calculate data from financial documents and statements (e.g., provider cost reports) as part of audit work.
• Use data mining and trend analysis tools to detect anomalies in Medicaid billing and payment patterns.
• Attend onsite audits to retrieve medical records and conduct provider entrance/exit conferences.
• Prepare and submit medical record request letters to providers related to requests for medical records or suspension overpayment determinations.
• Interpret and apply pertinent laws, regulations, policies, and procedures relevant to specific audit findings and provider type.
• Ensure Generally Accepted Government Auditing Standards (GAGAS) are applied to each applicable audit to identify fraud, waste, or abuse.
• Prepare factual, objective written reports in conformance with professional auditing and evaluation standards; present findings to leadership, external agencies, and government partners.
• Calculate improper payments and issue findings, recommendations, and corrective actions in accordance with applicable regulations, policies, and procedures.
• Prepare and send suspension overpayment determinations to providers when applicable.
• Communicate with federal/state agencies and providers regarding regulatory compliance, audit findings, and the recovery process.
• Attend briefings and presentations as assigned.
• Maintain fraud case development quality standards to ensure proper case development and complete, high-quality cases.
• Maintain proper and timely updates in relevant investigation tools and applications, including case development databases and documents.
• Develop and document reports of investigative findings, compile case file documentation, calculate improper payments, and issue findings, recommendations, and corrective actions as required.

Requirements

• Bachelor’s degree in finance, accounting, or related field required.
• 5–7 years of related experience in finance, accounting, or auditing.
• Intermediate knowledge of internal audit policies and operating principles.
• Intermediate knowledge and experience in auditing Medicare/Medicaid and other government payment and oversight programs (CMS, HRSA, OIG, DOE, Dept. of Commerce etc.).
• Knowledge and experience applying government accounting principles and standards, including Generally Accepted Government Auditing Standards (GAGAS).
• Experienced investigative skills.
• Strong data analysis skills.
• Knowledge of medical terminology, ICD-9-CM, ICD-10-CM, HCPCS level II, and CPT codes; utilize Medicaid and contractor guidelines for coverage determinations.
• Experience reviewing claims for appropriate billing and medical coding requirements, performing medical review, and/or developing fraud cases.
• Strong oral and written communication skills, strong interpersonal skills, and superior organizational abilities.
• Ability to take initiative, maintain confidentiality, meet deadlines, and work in a team environment.
• Ability to report work activity on a timely basis.
• Ability to work independently and as a team member to deliver high-quality work.
• Ability to multitask and prioritize assignments while meeting deadlines.
• Proficiency in Microsoft Office, specifically Microsoft Word and Excel.

Additional Requirements

• Must pass post-hire background screening checks.
• For remote work, required to have wired and/or wireless internet access.

Compensation & Benefits

• U.S. remote annual salary range: $55,000–$75,000/annual.
• For candidates in jurisdictions requiring range disclosure, the range is a good-faith estimate; final pay may vary by work location and job-related factors such as skills, experience, location, and internal equity. It is not a guarantee of compensation or salary.

Benefits available for full-time regular employees may include:

• Vacation
• Sick leave
• Paid holidays
• Health insurance
• Dental insurance
• Vision insurance
• Short- and long-term disability
• Life insurance
• Employee assistance plan
• 401(K) retirement plan
• Educational benefits

Location

Remote (U.S.).