Program Integrity Auditor

The Program Integrity Auditor provides detailed analysis, identifies improper payments, recommends corrective action, and strives to mitigate risk through provider education and support. The primary purpose of this position is to audit provider records to ensure that services meet these regulatory standards. Alliance is contractually obligated to implement measures to ensure that services are provided, billed and reimbursed in accordance with rules, regulations, coverage policies, laws, and contract requirements.

This position will allow the successful candidate to work a schedule that will be primarily remote. While there is no expectation of being in the office routinely, they will be required to come into the Alliance Office for business and team meetings as needed.

Responsibilities & Duties

Audit/Post-Payment Reviews

• Conduct routine and targeted post-payment audits of Medicaid and State funded providers to ensure that services are rendered and documented in accordance with established state and federal rules, regulations, policies, and terms of provider contractual agreements with the state
• Develop audit plans and tools based on the services to be audited
• Request and/or collect medical records, personnel records, policies/procedures, compliance plans, and other documents from providers based on audit plans
• Systematically and accurately collect, document, and store evidence
• Identify inappropriate billing and improper payments
• Document audit activities and findings in a detailed report
• Present audit results to leadership and Compliance Committee
• Attends appeal hearings to present and explain review findings
  
  

Provider Enrollment Due Diligence Reviews

• Conduct reviews of newly enrolled providers to ensure eligibility, qualifications, and/or licensure requirements are met per state and federal rules, regulations, policies, and terms of provider contractual agreements with the state
  
  

Regulatory Review/Research

• Diligently research clinical policies, administrative code, federal/state laws to assess for noncompliance
  
  

Data Analytics

• Analyze data from a variety of sources, including but not limited to claims, authorizations, enrollment, grievances, prior audits/investigations, incident reports, policies/procedures, to inform decision making
• Utilize various MicroStrategy and Healthcare Fraud Shield reports data during the audit process
  
  

Technical Assistance/Education

• Educates providers on the errors identified in the audit process
• Recognize when providers can improve through technical assistance (TA) rather than formal corrective action
• Recognize quality of care issues and make recommendations to appropriate entities/authorities
  
  

Provider Action and Follow-Up

• Document Improper Payment Charts, Statements of Deficiency, provides feedback and technical assistance to providers as needed/requested, and follows up on provider corrective action, as applicable
• Prepare for and participate in provider appeal process and/or court hearings to explain and defend audit findings
  
  

Travel

• Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc. may be required
• Travel to meet with members, providers, stakeholders, attend court hearings etc. is required
  
  

Minimum Requirements

Education & Experience

Bachelor’s degree in health care compliance, analytics, government/public administration, auditing, security management, criminal justice, or pre-law, from an accredited College/University and three (3) years of post-degree of experience in healthcare compliance, regulatory analysis, policy development, auditing, investigations, accreditation or any equivalent combination of related training and experience.

Preferred:

• Health care industry and/or Medicare/Medicaid/Behavioral Health knowledge
• Certification from AHFI, CFE, CPMA, CPC, CHC, or equivalent
• CLEAR Certified Investigator (Basic and Specialized)
• Clinical license as an LCSW, LCMHC, LMFT, LCAS, or LPA
  
  

Knowledge, Skills, & Abilities

• Knowledge of the Alliance Health service benefit plans and network providers
• Knowledge of Health care industry and/or Medicare/Medicaid/Behavioral Health knowledge
• Knowledge of the state and federal Medicaid laws, state and federal criminal and civil fraud laws, regulations, policies, rules, guidelines, service limitations, and various Medicaid programs
• Knowledge and proficiency in claims adjudication standards & procedures
• A general understanding of all major MCO functions, in particular as it relates to prior authorization, utilization reviews, grievance management, provider credentialing and monitoring
• High degree of integrity and confidentiality required handling information that is considered personal and confidential
  
  

Salary Range

$32.80 - $41.82/ Hourly

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity

An excellent fringe benefit package accompanies the salary, which includes:

• Medical, Dental, Vision, Life, Long Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility