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Alliance Health · 6 days ago

Program Integrity Auditor

Morrisville, NC

Full-time

Hybrid

Mid Level

$32.80/hr - $41.82/hr

3+ years exp

Alliance Health is focused on ensuring compliance within healthcare services, and they are seeking a Program Integrity Auditor to conduct audits and reviews of provider records. The role involves analyzing data, educating providers on compliance issues, and presenting findings to leadership to mitigate risks associated with improper payments.

Health Care

Responsibilities

Conduct routine and targeted post-payment audits of Medicaid and State funded providers to ensure that services are rendered and documented in accordance with established state and federal rules, regulations, policies, and terms of provider contractual agreements with the state

Develop audit plans and tools based on the services to be audited

Request and/or collect medical records, personnel records, policies/procedures, compliance plans, and other documents from providers based on audit plans

Systematically and accurately collect, document, and store evidence

Identify inappropriate billing and improper payments

Document audit activities and findings in a detailed report

Present audit results to leadership and Compliance Committee

Attends appeal hearings to present and explain review findings

Conduct reviews of newly enrolled providers to ensure eligibility, qualifications, and/or licensure requirements are met per state and federal rules, regulations, policies, and terms of provider contractual agreements with the state

Diligently research clinical policies, administrative code, federal/state laws to assess for noncompliance

Analyze data from a variety of sources, including but not limited to claims, authorizations, enrollment, grievances, prior audits/investigations, incident reports, policies/procedures, to inform decision making

Utilize various MicroStrategy and Healthcare Fraud Shield reports data during the audit process

Educates providers on the errors identified in the audit process

Recognize when providers can improve through technical assistance (TA) rather than formal corrective action

Recognize quality of care issues and make recommendations to appropriate entities/authorities

Document Improper Payment Charts, Statements of Deficiency, provides feedback and technical assistance to providers as needed/requested, and follows up on provider corrective action, as applicable

Prepare for and participate in provider appeal process and/or court hearings to explain and defend audit findings

Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc. may be required

Travel to meet with members, providers, stakeholders, attend court hearings etc. is required

Qualification

Healthcare complianceRegulatory analysisAuditingData analyticsProvider educationMedicare/Medicaid knowledgeTechnical assistanceClaims adjudicationClinical licenseAudit reportingIntegrityConfidentiality

Required

Bachelor's degree in health care compliance, analytics, government/public administration, auditing, security management, criminal justice, or pre-law, from an accredited College/University

Three (3) years of post-degree experience in healthcare compliance, regulatory analysis, policy development, auditing, investigations, accreditation or any equivalent combination of related training and experience

Knowledge of the Alliance Health service benefit plans and network providers

Knowledge of state and federal Medicaid laws, state and federal criminal and civil fraud laws, regulations, policies, rules, guidelines, service limitations, and various Medicaid programs

Knowledge and proficiency in claims adjudication standards & procedures

A general understanding of all major MCO functions, in particular as it relates to prior authorization, utilization reviews, grievance management, provider credentialing and monitoring

High degree of integrity and confidentiality required handling information that is considered personal and confidential