Auditor 3

Community Health, Department of; High Springs (FL); On-site; USD 53,000 - 74,000; Full time

Job summary

The State of Georgia, Department of Community Health seeks an Auditor 3 to conduct medical reviews and ensure compliance with SHBP policies. You will evaluate nursing standards, apply coding principles, and coordinate with divisions to monitor fraud, waste, and abuse across health programs.

Responsibilities include performing risk assessments, drafting narratives, and leading special projects related to payment integrity and regulatory compliance.

Qualifications

• Requires knowledge of nursing standards and protocols
• Experience with health care programs and SHBP policies
• Excellent report writing and communication skills
• Ability to interpret guidelines and policies
• Strong teamwork and independent problem solving

Responsibilities

• Conducts medical reviews following Office of Audits guidelines
• Evaluates nursing standards and nurse protocols for medical reviews
• Uses coding principles per AMA and health statistics standards
• Directs quality improvement activities for compliance
• Coordinates with divisions to monitor Fraud, Waste, and Abuse

Skills

Auditing skills

Fraud detection

Regulatory knowledge

Review and analysis

Interpersonal communication

Education

MS in Nursing, Psychology, Healthcare Administration

Accounting or Business-related degree

Job description

Explore a World of Opportunity with the State of Georgia! We are the force that drives Georgia! Georgia State Government is a large enterprise, composed of various agencies and entities with a common goal to improve the lives of Georgia's more than 10 million citizens! Join Team Georgia and impact lives everyday while receiving a robust benefits package designed for every stage of your career!

Job Title: Auditor 3 Agency: Department of Community Health Job Requisition ID: JR0000006585 Shift: Not Applicable (United States of America) Compensation Details: $53,310.72 - $73,677.24

Job Description:

• Conducts medical reviews and ensures the reviews are consistent with Office of Audits guidelines and in compliance with SHBP policies.
• Evaluates nursing standards and nurse protocols for all medical reviews.
• Utilizes coding principles in accordance with American Medical Association, National Center for Health Statistics and World Health Organization.
• Review state, federal, and other regulatory standards to direct quality improvement activities and achieve compliance.
• Coordinates with Divisions within the agency to effectively monitor Fraud, Waste, and Abuse.
• Collaborate with contracted vendors and staff to ensure SHBP providers are following SHBP policies and procedures, state, and federal laws.
• Track and monitor monthly and quarterly reports to ensure oversight of SHBP vendors' Special Investigation Unit activities identified in contracts.
• Participates in the planning, coordination, development and implementation of long-range goals and objectives for the Office of Inspector General.
• Coordinates on site visits at provider locations to facilitate utilization reviews.
• Effectively communicates with external and internal stakeholders at monthly meetings to mitigate fraud, waste, and abuse in the SHBP
• Leads special projects and participates in audits to ensure payment integrity of claims billed to SHBP.
• Performs claims data analysis to identify aberrant billing trends for providers enrolled in SHBP.
• Collaborates with Audit Supervisor and Director to detect, prevent, and investigate providers for fraud, waste, and abuse.
• Conduct performance, operational, financial and/or compliance audit projects
• Perform thorough and accurate risk assessments effectively scoping engagements
• Ensure working papers are clear, concise, and accurate; work papers are prepared in accordance with applicable standards and Department policies and procedures and are well organized
• Plan projects in a clear, logical and reasonable manner; ensure effective use of resources
• Establish the appropriate methodology for the audit based on the objectives of the audit
• Analyze audit documentation including financial statements, budgetary compliance reports, and claims data
• Conduct interviews and walkthroughs to assist in the evaluation of internal controls
• Write narratives and conclusions based on the findings derived from the audits
• Organize audit work according to policies and procedures
• Assist and prepare manuscripts and reports
• Communicate audit and compliance information such as results and conclusions in accordance with professional standards and the Department policies and procedures
• Perform other duties as assigned

Preferred Qualifications

• Knowledge of the administration and organization of nursing services.
• Knowledge of professional nursing theory, procedure and techniques.
• Knowledge of state and federal laws and regulations governing the practice of nursing and the provision of health care to clients.
• Ability to interpret policy.
• Team player, self-starter, results driven.
• Ability to problem-solve, identify solutions and work independently and part of a team when required
• M.S. degree in Nursing, Psychology, Healthcare Administration, or similar clinical programs.
• Certified Fraud Examiner or Accredited Health Care Fraud Examiner.
• Experience with monitoring, investigations, case management, identifying and reviewing claims and auditing of health care programs.
• Experience in the preparation, review and delivery of formal medical/investigative reports including relevant statistical summaries and qualitative analysis of findings.
• Knowledge of statistical data and reporting.
• Accounting or Business-related degree
• Strong governmental accounting and auditing skills

Minimum Qualifications: High school diploma/GED and four (4) years of job-related experience; or two (2) years of experience required at the lower level Complnc Specialist 2 (RCP061) or position equivalent.--Note: Some positions may require a certification or licensure. --Note: Some positions may require a valid driver's license.

Equal Employment Opportunity Employer The State of Georgia does not discriminate based on race, color, national origin, sex, religion, age, disability, or other protected categories in employment or the provision of services. Qualified applicants may request reasonable accommodation when needed during the application and/or screening process by contacting the appropriate agency Human Resources department.

Georgia State Government is a large enterprise, composed of various entities with a common goal to improve the lives of Georgia's 10 million citizens. With nearly 62,000 employees, we are one of the single largest employer in the state. Public service opportunities stretch across the state as employees live and work in all 159 counties. From traditional fields such as accounting, nursing, and engineering to unique fields like forestry and natural resources management, Georgia state government provides a world of opportunity.