Program Integrity Auditor

Position Summary The Program Integrity Auditor reviews records for medical, behavioral, transportation, and other healthcare providers. The auditor determines correct coding and appropriate documentation during the review of medical records. Activities include audits of provider records to ensure coding and documentation standards are met, recommending follow‑up action (provider education, recoupment of funds, rebilling of claims), and referral to state regulators for suspected fraud, waste, or abuse (FWA). The auditor ensures state and federal requirements are met and flags concerning billing patterns or trends. Primary Responsibilities Serve as an audit team member for health plans that administer benefits to Medicaid members across multiple lines of business, including acute care, behavioral health, developmental disabilities, and children in out‑of‑home care. Audit records routinely and on an ad hoc basis for all lines of business to ensure coding and documentation meet regulatory standards, including code usage, modifier usage, and place‑of‑service usage. Coordinate audit documentation and reports for review by internal and external staff and stakeholders. Identify aberrant billing patterns and potential FWA, report findings to internal staff, and assist with further investigation or reports to state regulators. Assist with development and implementation of plans for prospective and retrospective FWA avoidance, detection, and referral. Assist with creation and submission of regulator deliverables through timely audit activities. Provide technical assistance and education to providers, including training on regulatory requirements and coding and documentation rules. Maintain compliance with company policies and procedures. Perform other duties as assigned. Required Qualifications 3–5 years of experience reviewing and interpreting claims data and medical records. 3–5 years of experience with standard industry coding guidelines such as CPT, HCPCS, and ICD‑10. Willingness to work Monday–Friday from 8:00 a.m. to 5:00 p.m. Arizona Time Zone. Must possess an active CPC (Certified Professional Coder), CCS (Certified Coding Specialist), or CPMA (Certified Professional Medical Auditor) license. Preferred 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 presentation skills. Strong communication skills, both written and verbal. Adaptability in a flexible environment. Education Associate's degree or equivalent experience (2+ years of relevant experience + high school diploma or GED). Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $46,988.00 – $122,400.00. This represents the base hourly rate or base annual salary for all positions in the grade. The actual base salary offer will depend on experience, education, geography, and other factors. The position is eligible for a CVS Health bonus, commission, or short‑term incentive program in addition to the base pay. Benefits Medical, dental, and vision coverage. Paid time off. Retirement savings options. Wellness programs and other resources. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws. #J-18808-Ljbffr NACBA