SME - Medicaid Program Integrity and Claims Audits

Senior Consultant For Medicaid Program Integrity And Claims Audits

BerryDunn is seeking a Senior Consultant with subject matter expertise in Medicaid program integrity and claims audits to assist clients with prevention and detection of fraud, waste, and abuse. This individual will be responsible for assisting with risk assessment, external audit coordination, interpretation and application of Medicaid policy and applicable code of federal regulations, and conducting Medicaid medical, dental, behavioral health, and pharmacy claims audits.

You will work remotely, hybrid, or in one of our offices, mainly helping client in Guam. You will report to and partner with Government Assurance Practice Group management team members for both client work and career development. With a growth mindset, you will drive your own development with support from our management team.

Travel Expectations: Travel to client sites can range up to 50%.

Responsibilities

• Establish and monitor Medicaid program integrity objectives, and key performance indicators (KPIs).
• Ensure the Medicaid program integrity policies and procedures meet federal and state policies and grants compliance.
• Research Medicaid policies and regulations.
• Advise and assist clients in translating Medicaid policy and program needs into system requirements and change requests, ensuring the State's program, policy, and business objectives are accurately captured using industry-standard language.
• Provide frequent, clear, and consistent communication to the client, team members, and vendors.
• Develop or update policies and procedures related to Medicaid program integrity.
• Develop corrective action plans to solve program problems.
• Analyze Medicaid program integrity reports.
• Assist in the development and train the agency on program requirements.
• Serve as a senior systems advisor with a strong understanding of the system implementations.
• Review and audit Medicaid claims for accuracy, legality, and reasonableness
• Make accurate and informed recommendations on claims based on Medicaid policies and regulations and claims data.
• Document and report audit findings to management
• Stay up-to-date with changes in Medicaid regulations and industry trends
• Medicaid systems research and analysis, including but not limited to, member benefit groups, billing codes, system configuration, service limits, system requirements, and electronic billing standards.
• Provide quality assurance reviews of work completed by peers

Qualifications

• Excellent communication skills
• Ability to conduct research and analysis related to Medicaid policies.
• Medical claims billing or adjudication experience.
• Strong communication skills and attention to detail.
• Bachelor's Degree (BA/BS)—May substitute four years of applicable experience for degree.
• Knowledgeable in quality assurance/control procedures and demonstrated proactive problem management skills.
• Demonstrated ability to excel in a team setting.
• Strong experience with Microsoft applications and artificial intelligence
• Willingness to travel
• Willingness to work flexibly to serve clients in different time zones

Preferred Qualifications:

• Prior consulting experience in a national or regional consulting firm, and experience working in/with a state Medicaid agency
• Experience with government agencies, ideally working with Medicaid program integrity units
• Experience with fraud risk assessments
• Experience with internal audits
• Preference will be given to candidates with any of the following certifications:
• Certified Professional Coder (CPC) or equivalent
• Certified Fraud Examiner (CFE) or equivalent
• Certified Professional Medical Auditor (CPMA) or equivalent.
• Certified Internal Auditor (CIA) or equivalent

Compensation Details

The base salary range targeted for this role is $120,000 - 140,000. This salary range represents BerryDunn's good faith and reasonable estimate of the range of possible compensation at the time of posting. If an applicant possesses experience, education, or other qualifications more than the minimum requirements for this posting, that applicant is encouraged to apply, and a final salary range may then be based on those additional qualifications; compensation decisions are dependent on the facts and circumstances of each case. The salary of the finalist selected for this role will be based on a variety of factors, including but not limited to, years of experience, depth of experience, seniority, merit, education, training, amount of travel, and other relevant business considerations.

BerryDunn Benefits & Culture

Our people are what make BerryDunn special, and in return we strive to support our employees and help them thrive. Eligible employees have access to benefits that go beyond what's expected to support their physical, mental, career, social, and financial well-being. Visit our website for a complete list of benefits and a look into our culture: Experience BerryDunn.

We will ensure that individuals are provided reasonable accommodation to participate in the job application or interview process or perform essential job functions. Please contact View email address on click.appcast.io to request an accommodation.

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace.

About BerryDunn

BerryDunn is the brand name under which Berry, Dunn, McNeil & Parker, LLC and BDMP Assurance, LLP, independently owned entities, provide services. Since 1974, BerryDunn has helped businesses, nonprofits, and government agencies throughout the US and its territories solve their greatest challenges. The firm's tax, advisory, and consulting services are provided by Berry, Dunn, McNeil & Parker, LLC, and its attest services are provided by BDMP Assurance, LLP, a licensed CPA firm.

BerryDunn is a client-centered, people-first professional services firm with a mission to empower the meaningful growth of our people, clients, and communities. Led by CEO Sarah Belliveau, the firm has been recognized for its efforts in creating a diverse and inclusive workplace culture, and for its focus on learning, development, and well-being. Learn more at berrydunn.com.