Program Integrity Auditor
$46,988–$122,400 year
RemoteUnited States
Job Summary
Review medical, behavioral, and transportation provider records to ensure coding and documentation standards align with state and federal regulations. Identify aberrant billing patterns and potential fraud, waste, or abuse, then recommend follow-up actions such as provider education, fund recoupment, or referrals to state regulators. Coordinate audit documentation and reports for internal and external stakeholders while assisting with the development of FWA avoidance and detection plans. Provide technical assistance and training to providers on regulatory requirements, coding guidelines, and documentation rules. Maintain compliance with company policies and procedures while performing other duties as assigned.
Required Qualifications
- 3-5 years of experience in reviewing and interpreting claims data, as well as medical records and appropriate documentation
- 3-5 years of experience with standard industry coding guidelines such as CPT, HCPCs, and ICD-10
- Willingness to work Monday-Friday from 8am-5pm Arizona Time Zone
- Must possess an active CPC (Certified Professional Coder), CCS (Certified Coding Specialist), or CPMA (Certified Professional Medical Auditor) license
- Associate's degree or equivalent experience (2+ years of relevant experience + high school diploma or GED)
Desired Qualifications
- Previous auditing experience
- Previous Medicaid and/or health plan experience, including AHCCCS (Arizona Health Care Cost Containment System)
- Previous experience with QuickBase
- Strong analytical and critical thinking skills
- Strong attention to detail
- Ability to collaborate and work with a team, as well as work independently as needed
- Excellent presentational skills
- Strong communication skills, both written and verbal
- Ability to be adaptable in a flexible environment
Hiring someone like this?
Get your role in front of qualified candidates on Sorce.