Senior Consultant – Medicaid Program Integrity

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

📋 Description

• Perform comprehensive evaluations of Medicaid claims along with reviewing provider, member, eligibility, financial, and operational data.

• Detect, document, and report potential fraud, waste, abuse, improper payments, compliance issues, and operational risks.

• Assess claims for precision, compliance, reasonableness, alignment with policies, regulations, program requirements, and coding standards.

• Assist in reviewing provider management, member services, financial management, and TPL operational data.

• Compile case summaries, findings, recommendations, workpapers, and supporting documentation for audits and investigations.

• Research, interpret, and apply Medicaid policies, program integrity requirements, and regulations.

• Contribute to the development of controls, monitoring strategies, review protocols, audit tools, documentation standards, and process enhancements.

• Aid in the revision of Medicaid program integrity policies and procedures.

• Provide training, knowledge transfer, and technical support for client staff.

• Utilize Jira, SharePoint, Microsoft Office, Teams, Outlook, and other relevant Medicaid or vendor systems for tracking, documentation, coordination, reporting, and follow-up.

• Assist with onsite planning, workgroup sessions, client leadership preparations, release activities, and project requirements.

• Collaborate with MQD staff, audit and TPL specialists, data analysts, compliance personnel, vendor partners, and members from cross-functional workstreams.

⛳️ Requirements

• At least three (3) years of experience in conducting Medicaid claims audits, investigations, and/or compliance reviews.

• Familiarity with Medicaid Program Integrity principles, including fraud, waste and abuse, provider oversight, payment integrity, TPL, claims audits, or cost avoidance concepts.

• Experience in developing or supporting audit findings, corrective action plans, executive-ready reports, analytical summaries, methodology documentation, quality checks, or recurring performance reports.

• Strong skills in analytics, documentation, quality assurance, and stakeholder coordination.

• Proficient in using SharePoint, Microsoft Teams, Outlook, Excel, or similar tools.

• Capability to research and analyze Medicaid policies, claims, provider oversight, payment integrity, and program integrity requirements.

• Skill to manage sensitive program, operational, provider, member, client, PII/PHI, and HIPAA-related information in line with confidentiality and data-security standards.

• Availability to work during Hawaii Standard Time hours.

• Willingness to travel approximately 30%–50% of the time, including trips to Hawaiʻi.

• Preferred experience in Medicaid fraud risk assessments, TPL, PERM, payment integrity, and public-sector health-program analytics.

• Preferred experience in reviewing Medicaid medical, dental, behavioral health, and pharmacy claims.

• Preferred experience in coordinating with client stakeholders, vendor partners, project leadership, and cross-functional workstreams.

• Relevant certifications such as CPC, CHC, CPMA, CFE, CIA, or equivalent are preferred.

• Preferred experience with Jira, SQL, Power BI, Tableau, or other comparable analytics and dashboarding tools.

🏝️ Benefits

• Flexible work locations, including fully onsite, hybrid, or remote options.

• Benefits that promote physical, mental, career, social, and financial well-being.

• Reasonable accommodations provided for the application, interview, and job-performance processes.

• Focus on learning, development, and overall well-being.

• An equal employment opportunity workplace.