Program Integrity Audit Analyst II

Summary: CoventBridge Group is the global leader in full-service investigations, and they are seeking a Program Integrity Audit Analyst II to perform evaluations and develop leads associated with performance audits of Medicaid Managed Care Plans. This role involves identifying potential fraud, waste, and abuse, issuing findings and recommendations, and ensuring improved healthcare delivery through effective audit strategies. Responsibilities: - Understanding of state Medicaid programs and managed care plan delivery systems - Planning, coordinating, and conducting performance audits in accordance with Government Auditing Standards - Understanding managed care encounter data and determining areas that require improved program integrity oversight - Designing and implementing audit strategies for performing provider payment reviews and managed care plan performance audits using independent judgment to formulate a plan of action and direction in complex audit scenarios - Work with auditors to develop audit plans clearly defining scope, steps, and tasks to achieve stated audit objectives including plans of action for audit development and information request processing - Documenting specific findings and recommendations for improved contract compliance and process improvement; and identifying any improper payments with conclusions based on rule, policy, and billing instructions - Developing and supporting findings that accurately report condition, criteria, cause, and effect and proposes viable recommendations for corrective actions, as applicable - Prioritization and assignment of workload, ensuring adherence to task order policies and procedures - Preparing factual and objective written reports in conformance with professional auditing and evaluation standards - Ensure findings are well defined and are fully supportable and required reports are submitted according to pre-established time guidelines - Interpret and apply pertinent laws, regulations, policies, and procedures relevant to the specific audit findings - Conduct matrix review meetings with auditors to ensure thorough and timely completion of assigned audit tasks in accordance with task order guidelines and direction from CMS - Prepare and submit medical record request letters to providers associated with requests for medical record requests or suspension overpayment determinations - Serve as mentor/trainer to new Program Integrity staff - Perform other duties as assigned by PI Audit Supervisor or the PI Manager, Deputy PI Manager, PI Project Manager, or Medicaid Operations Lead Required Qualifications: - Understanding of state Medicaid programs and managed care plan delivery systems - Planning, coordinating, and conducting performance audits in accordance with Government Auditing Standards - Understanding managed care encounter data and determining areas that require improved program integrity oversight - Designing and implementing audit strategies for performing provider payment reviews and managed care plan performance audits using independent judgment to formulate a plan of action and direction in complex audit scenarios - Work with auditors to develop audit plans clearly defining scope, steps, and tasks to achieve stated audit objectives including plans of action for audit development and information request processing - Documenting specific findings and recommendations for improved contract compliance and process improvement; and identifying any improper payments with conclusions based on rule, policy, and billing instructions - Developing and supporting findings that accurately report condition, criteria, cause, and effect and proposes viable recommendations for corrective actions, as applicable - Prioritization and assignment of workload, ensuring adherence to task order policies and procedures - Preparing factual and objective written reports in conformance with professional auditing and evaluation standards - Ensure findings are well defined and are fully supportable and required reports are submitted according to pre-established time guidelines - Interpret and apply pertinent laws, regulations, policies, and procedures relevant to the specific audit findings - Conduct matrix review meetings with auditors to ensure thorough and timely completion of assigned audit tasks in accordance with task order guidelines and direction from CMS - Prepare and submit medical record request letters to providers associated with requests for medical record requests or suspension overpayment determinations - Serve as mentor/trainer to new Program Integrity staff - Perform other duties as assigned by PI Audit Supervisor or the PI Manager, Deputy PI Manager, PI Project Manager, or Medicaid Operations Lead - Excellent research and organization, prioritization, and time management skills - Excellent verbal and written communication skills - Ability to work independently with minimal supervision - Ability to multi-task in a fast-paced environment - Proficiency with Microsoft Word and Excel required - High School Diploma or G.E.D. equivalent, with preference given to those candidates who have successfully completed college or technical degree programs related to the position (e.g., Criminal Justice, Statistics, Data Analysis, etc.) - Minimum of one (1) year of experience conducting performance or compliance audits, with preference given to those who have conducted audits involving state Medicaid programs, or one (1) year of experience with an advanced degree preferred Preferred Qualifications: - Knowledge of statistics, data analysis techniques, and PC skills are preferred - Experience with an inventory management and reporting system preferred - Candidates with Certified Fraud Examiner (CFE) Certifications will be given priority consideration Required Skills: Medicaid programs knowledge, Performance audits experience Important Skills: Data analysis techniques, Certified Fraud Examiner, Microsoft Word proficiency, Microsoft Excel proficiency Nice-to-Have Skills: Research skills, Multi-tasking ability, Organization skills, Time management skills, Verbal communication skills, Written communication skills, Independent work ability Benefits: Medical, Dental, Vision plans, Life, LTD and STD paid by the employer, 401(k) with company match up to 4%, Paid Time Off and company paid holidays, Tuition assistance after 1 year of service