Location
Wyoming, MI | United States
Job description
Description and Functions
Open Until Filled
GENERAL DESCRIPTION: The Wyoming Department of Health, Division of Healthcare Financing (DHCF), Program Integrity (PI) Section is seeking a talented professional to join our team as a PI Audit/Investigation Analyst
. This is an excellent opportunity for someone with strong analytical and problem-solving skills who is interested in building a career in the Medicaid audit, investigation, and compliance space.
The PI Audit/Investigation analyst is responsible for planning, directing, administering, and reporting on State Plan provider audits and investigations, provider self-reporting, and provider self-audits. This position reports to the Program Integrity Audit, Investigation, and Data Management Supervisor.
This position is an At-Will Employment Contract (AWEC) and includes a single Health Insurance plan. This position pays for actual hours worked and is limited to 40 hours per week. This position does not include paid vacation time, paid sick time, paid holidays, family health insurance, retirement, or other benefits. These items are not negotiable by the hiring manager.
Human Resource Contact: [email protected] ESSENTIAL FUNCTIONS: The listed functions are illustrative only and are not intended to describe every function which may be performed at the job level.
Facilitate Audit and Investigative Operations and Quality & Performance Standards - Plan, conduct, and report on independent audits/investigations of Wyoming Medicaid State Plan providers
- Develop Program Integrity auditing/investigation standards, policies, and procedures for planning, organizing, conducting, and documenting audits/investigations
- Identify resources available for successful and timely completion of audits/investigations; serve as lead audit/investigator for desk and field audits/investigations; assign tasks and monitor the progress of audit/investigation teams; document sampling methods
- Obtain and review audit/investigation documentation, perform audit/investigation duties, make remediation and corrective action plans based on audit/investigation findings
- Draft initial and final findings report program recommendations, corrective action plans, etc.
- Make independent recommendations for the initiation of overpayment recovery and/or payment suspension actions based on audit/investigative findings
- Testify on audit/investigation findings at contested case hearings and civil or criminal legal proceedings
- Make recommendations and identify areas requiring further investigation by the Audit, Investigation, and Data Management Supervisor
- Assist Program Integrity leadership in reviewing and updating Wyoming Medicaid Rules, regulations, policies, and procedures to introduce and facilitate electronic submission of information and reporting by providers using the fraud, waste, and abuse case management provider portal
Review and Interpret Data Analytics - Perform preliminary studies, random sampling of Medicaid claims, data mining, data analysis, data organization, and evaluation of results and findings with tables, charts, graphs, written reports, and white papers
- Monitor claims system edits and communicate recommendations verbally and in formal written documents for system edit remediation when anomalies or vulnerabilities are identified related to billing errors or waste of program services and resources
- Report provider non-compliance related to waste and abuse verbally and in formal written documents to PI and Division leadership
Develop Audit/Investigation Strategy - Identify audit/investigation areas and the execution of audit/investigation activities to measure provider compliance with Medicaid requirements, rules, and policies
- Conduct “planned” audits/investigations of Medicaid State Plan provider groups
- Draft preliminary audit/investigation plans including type, objectives, authority, background, review period, sampling method, timeline for completion, provider notification, and all communication of findings
- Draft and deliver audit/investigation reporting, summaries, and findings
- Conduct and support desk and provider field audits/investigations
Qualifications
PREFERENCES:
Preference will be given to candidates with:
A High School Diploma or G.E.D. equivalent, with preference given to those candidates who have completed college or technical degree programs related to the position (e.g., Accounting, Business, Criminal Justice, Paralegal, Public Administration, Healthcare Administration, Data Analysis, or in a field of study that can be reasonably interpreted to perform tasks related to this position).
Candidates with Certified Fraud Examiner (CFE) or Certified Professional Coder (CPC) certifications will be given priority consideration
At least 1-3 years of progressive work experience in healthcare auditing/investigating, healthcare finance, compliance, quality assurance/compliance analysis or other related field, advanced report writing skills (public accounting, public administration, healthcare administration, auditing, investigating, advanced interviewing skills)
KNOWLEDGE: - Knowledge of state and federal government functions, policies, procedures, rules, and laws, including Medicaid law and regulatory structure
- Knowledge of and understanding of healthcare delivery and regulatory systems (government-financed and private systems), benefits, resources, industry standards, and best practices related to claims processing and compliance, healthcare coding systems (CPT, HCPCS, ICD-10), and billing practices
- Knowledge of challenges and trends in healthcare service provisions, quality assurance, and continuous improvement methodologies
- Knowledge of fraud, waste, and abuse detection methods and systems
- Working knowledge and effective use of Microsoft Suite including Word, Excel, and PowerPoint, and business intelligence tools.
- Skill in time management and workload planning; capable of working both independently and in a team environment
- Excellent verbal and written communication skills, including technical writing and the preparation of reports, educational, and informational materials for a wide range of audiences
MINIMUM QUALIFICATIONS: None - See "Preferences"
Necessary Special Requirements
PHYSICAL WORKING CONDITIONS :
- Typically, the employee will sit comfortably to perform the work, however, there may be some walking, standing, bending, and carrying light items
NOTES: - FLSA: Non-Exempt
- The Wyoming Department of Health is an E-Verify employer.
Supplemental Information
048-Wyoming Department of Health - Division of Healthcare Financing
Click here to view the State of Wyoming Classification and Pay Structure.
URL:
The 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.
Non Benefit Position
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