Senior Medical Audit Specialist

Senior Medical Audit Specialist

At the Oklahoma Health Care Authority (OHCA), your work matters. Every day, our team helps ensure Oklahomans have access to better health and better care. Guided by our core values, we foster a workplace where people feel supported, respected, and empowered to make an impact.

Let's Talk Benefits

We know your great work deserves great support. Here's a snapshot of what we offer for all eligible employees:

• Generous state-paid benefit allowance to offset insurance premiums.
• A wide selection of insurance plans with no pre-existing condition exclusions.
• Flexible Spending Accounts for health care and dependent care.
• Retirement Savings Plan with employer contributions.
• 11 paid holidays annually.
• 15 days of vacation and 15 days of sick leave in the first year.
• Longevity Bonus recognizing years of public service.
• Public Service Loan Forgiveness eligibility and tuition reimbursement.
• Wellness benefits, including an on-site gym and fitness center discounts.

Job Description

Location: 4345 N Lincoln Blvd, Oklahoma City, OK 73105

Salary: $78,465.00/annual

Work Schedule: Monday Friday

Primary Hours: 8:00 a.m. 5:00 p.m.

Agency/Division Information

The Oklahoma Health Care Authority (OHCA) works to ensure Oklahomans have access to better health and better care. The agency's core values include passion for purpose, trust and transparency, empowerment and accountability, best in class and outcome-driven, and servant leadership.

Position Purpose

The Senior Medical Audit Specialist plays a critical role in safeguarding the integrity of healthcare services by providing clinical expertise in conducting audits and investigations to combat fraud, waste, and abuse. This position ensures compliance with OHCA policies, state statutes, and federal regulations through detailed analysis of billed services and documentation. By collaborating with internal and external stakeholders, the Senior Medical Audit Specialist helps to promote accountability and transparency in billing practices, supporting the overall mission of the Oklahoma Health Care Authority to provide better health and care for Oklahomans.

Essential Functions May Include:

• Provide clinical expertise in conducting investigations and completing comprehensive clinical audits in an effort to combat fraud, waste, and abuse.
• Ensure billing compliance with OHCA policy, state statutes, and federal regulations.
• Performs analysis and evaluation of billed services including claims and documentation to ensure all HCA policy requirements are met and services are clinically/medically appropriate.
• Collaborate with others across the unit, organization, and external entities to evaluate audit results and make referrals to appropriate parties.
• Communicate audit findings to all stakeholders.
• Represents the Provider Audits Unit before an Administrative Law Judge (ALJ) and in legal proceedings regarding any general provider appeals, in an informed and professional manner.
• Maintain licensure and certifications.
• Other duties as assigned.

Supervisory Responsibilities: This position does not supervise.

Knowledge, Skills, Abilities and Competency Requirements

The Senior Medical Audit Specialist requires in-depth knowledge of healthcare policies, state and federal regulations, and audit processes, as well as the ability to analyze complex billing data and ensure compliance. Strong communication and collaboration skills are essential to effectively convey audit findings and work with various stakeholders. This role demands strategic problem-solving and organizational skills to manage multiple tasks and resolve complex issues.

Education and/or Experience: Possession of a valid permanent Oklahoma license as a Registered Nurse (RN) as approved by the Oklahoma Board of Nursing or Registered Nurse License recognized by the Enhanced Nurse Licensure Compact (eNLC) AND 5 years of professional experience as a registered nurse. There is no substitution for licensure.

Preference Qualifications Include:

• Certifications in any of the following areas: Certified Professional Medical Auditor (CPMA), Certified Professional Coder (CPC)
• General understanding of coding principles (CPT, HCPCS, ICD-10 and/or DRG)
• Experience with Medicaid and Medicare billing audits
• Experience in medical review, auditing, utilization review, compliance or regulatory work.

Physical Demands and Work Environment

Work is typically performed in an office setting with climate-controlled settings and exposure to moderate noise levels. In the course of performing job duties, employees are required to speak, stand, walk, and reach with their hands and arms. This position requires extended periods of sitting and daily use of computers and phones. Employees must be willing to complete all job-related travel associated with this position. Being present at the office is an essential function of this position.

Accommodation Statement

The Oklahoma Health Care Authority complies with applicable State and Federal civil rights laws and does not discriminate. All qualified applicants will receive consideration for employment without regard to race, color, sex, religion, disability, age, national origin, or genetic information. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact the Civil Rights Coordinator at View phone number on click.appcast.io.