Program Integrity Auditor

This is a fully remote position, open to applicants in Arizona.

📋 Description

• Act as a member of the audit team for a health plan(s) that currently provides benefits to Medicaid members across various lines of business, including acute care, behavioral health, services for individuals with developmental disabilities, and children in out-of-home care.

• Regularly audit records as well as conduct ad hoc audits for all lines of business to ensure that coding and documentation comply with regulatory standards.

• Organize audit documentation and reports for review by internal and external staff and stakeholders.

• Detect unusual billing patterns and potential fraud, waste, and abuse (FWA), reporting findings to internal staff.

• Assist in further investigations and/or compile reports for state regulators using developed critical thinking abilities.

• Support the development and execution of plans for prospective and retrospective FWA prevention, detection, and referral.

• Contribute to the preparation and submission of regulatory deliverables by completing timely audit activities.

• Offer technical assistance and training to providers, focusing on regulatory requirements, coding, and documentation rules.

• Ensure adherence to company policies and procedures.

• Perform additional duties as assigned.

⛳️ Requirements

• 3-5 years of experience in analyzing and interpreting claims data.

• 3-5 years of experience with standard industry coding guidelines such as CPT, HCPCS, and ICD-10.

• Availability to work Monday to Friday from 8am to 5pm Arizona Time Zone.

• Must hold an active CPC (Certified Professional Coder), CCS (Certified Coding Specialist), or CPMA (Certified Professional Medical Auditor) license.

• Previous auditing experience is required.

• Experience with Medicaid and/or health plans, including AHCCCS (Arizona Health Care Cost Containment System).

• Familiarity with QuickBase is preferred.

• Strong analytical and critical thinking abilities.

• High attention to detail.

• Ability to collaborate effectively with a team while also working independently as needed.

• Excellent presentation skills.

• Strong verbal and written communication skills.

• Capacity to adapt in a flexible work environment.

🏝️ Benefits

• Medical, dental, and vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Comprehensive benefits package.