Medical Program Auditor/ Analyst

University of Massachusetts Medical School; Westborough (MA); Hybrid; USD 70,000 - 100,000; Full time

Job summary

University of Massachusetts Medical School seeks a Fraud, Waste, and Abuse Auditor to identify, investigate, and prevent fraudulent activity in Medicaid programs. You will conduct data mining, claims analysis, and medical record reviews, perform onsite audits, and prepare detailed audit documentation.

The role requires up-to-date knowledge of CPT/HCPCS/ ICD-10 coding, strong analytical skills, and the ability to travel within Massachusetts for audits; most work is remote with periodic onsite

Qualifications

• Bachelor's degree in business, healthcare administration, or related field or equivalent experience.
• 4-6 years in healthcare, with at least two years in data mining, audits or claims analysis.
• Knowledge of CPT/HCPCS/ ICD-10 coding and billing policies.
• Strong analytical and problem solving skills with ability to identify root causes.

Responsibilities

• Conduct data mining and claims analysis to detect fraudulent, wasteful or non-compliant billing.
• Perform desk and onsite audits to assess records and regulatory compliance.
• Prepare audit documentation, findings, and case files; calculate sanctions and overpayments.
• Communicate audit findings with providers and support recovery processes.
• Stay current with regulations, coding changes, and industry standards.
• Assist with case management and record retention procedures.

Skills

Data mining

Analytical thinking

Regulatory interpretation

Communication

Problem solving

Multi-tasking

Education

Bachelor's degree in business or healthcare administration

Tools

Microsoft Excel

Microsoft Word

PowerPoint

Access

Job description

Overview

Under the general direction of the Associate Director or designee, the Fraud, Waste, and Abuse (FWA) Auditor serves a crucial role in identifying, investigating, and preventing fraud, waste and abuse for Medicaid programs. A major function of this position is to conduct desk and onsite audits across various provider types to ensure compliance with federal and state regulations. The Auditor performs investigative activities to develop leads and detect aberrant billing practices, including data mining, claims analysis, and medical record assessment.

Onsite requirement 1-2 times per month, all other aspects of the job are remote.

Responsibilities

Responsibilities:

• Ensure compliance with federal and state regulations and healthcare FWA industry standards.
• Perform independent data mining and data analysis utilizing claims data to detect patterns and trends that may uncover fraud, waste, or non-compliant billing practices.
• Conduct onsite audits as required, to assess the completeness of medical and administrative records and the compliance with applicable regulatory requirements.
• Prepare detailed audit documentation, summaries of investigative findings, compile case files, calculate sanctions and overpayments based on violations cited.
• Communicate with providers regarding issues such as general regulatory compliance, audit findings, and the recovery process.
• Recommend policy, procedure and system changes to enhance investigative outcomes.
• Update appropriate internal management staff regularly on progress of investigations.
• Stay current with regulatory updates, coding changes, and industry standards.
• Identify trends from national fraud-related publications and recommend new or improved strategies to strengthen fraud-detection efforts.
• Assist with document management, updating case-tracking system and adhering to record retention policies and procedures.
• Perform other duties as assigned.

Qualifications

Qualifications:

• Bachelor's degree in business, health care administration, or other related field or an equivalent combination of education and experience
• 4-6 years of related experience in the healthcare industry, business,; with at least two years of experience conducting data mining in the healthcare insurance industry, healthcare claim audits, administrative medical record reviews or other claims analysis related experience
• Knowledge of CPT, HCPCS and ICD-10 coding, reimbursement and claims processing policies
• Strong analytical and qualitative skills as well as problem solving skills with the ability to look for root causes and implement workable solutions
• Ability to interpret and apply law and regulations as it relates to fraud and fraud investigations
• Ability to multi-task, establish priorities and work independently and collaboratively to achieve audit objectives
• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint and Access)
• Excellent Customer service skills with the ability to interact professionally and effectively with providers, clients, and internal stakeholders from all departments
• Ability to travel within Massachusetts and be on-site as needed for audits

Additional Information

Preferred Qualifications:

Prefer individual possessing any of the following certifications or licensure: CPC or CPMAKnowledge of state and federal regulations as they apply to public assistance programs