Program Integrity Auditor (Full-time Hybrid, North Carolina Based)

Alliance Health; Morrisville (NC); Hybrid; USD 46,000 - 59,000; Full time

Benefits offered by this job

Medical benefits

Retirement plan

Hybrid/Remote options

PTO and holidays

Dress code flexibility

Job summary

Alliance Health is seeking a Program Integrity Auditor to perform post-payment and prepayment audits of Medicaid and state-funded providers. You will analyze data, identify improper payments, and document findings for leadership review. The role requires collaboration across regulatory, clinical, and operational teams.

The position is full-time and hybrid, with travel to Alliance catchment areas as needed. A Bachelor's degree in health care compliance or related field plus 3 years of experience

Qualifications

• Bachelor’s degree in health care compliance, analytics, government/public administration, auditing, security management, criminal justice, or pre-law with 3 years of post-degree healthcare compliance experience.

Responsibilities

• Conduct post-payment and prepayment audits of Medicaid and state-funded providers to ensure compliance.
• Develop audit plans and tools based on services audited.
• Request and collect medical records and related documents for audits.
• Document evidence and audit findings in detailed reports and present results to leadership.
• Perform provider enrollment due diligence and assess licensure and qualifications.
• Research clinical policies and applicable laws to identify noncompliance.
• Analyze data from claims, authorizations, enrollment, grievances, and audits to inform decisions.
• Educate providers on audit findings and recommend corrective actions.
• Travel as needed to meet with members, providers, and stakeholders.

Skills

Medicaid knowledge

Auditing

Data analytics

Regulatory analysis

Claims adjudication

Education

Bachelor's degree in health care compliance/analytics

Bachelor's degree in auditing/administration

Job description

The Program Integrity Auditor provides detailed analysis, identifies improper payments, recommends corrective action, and strives to mitigate risk through provider education and support. The primary purpose of this position is to audit provider records to ensure that services meet these regulatory standards. Alliance is contractually obligated to implement measures to ensure that services are provided, billed and reimbursed in accordance with rules, regulations, coverage policies, laws, and contract requirements.

This is a full-time hybrid opportunity. There is no expectation of coming into the office routinely, however, the selected candidate must be available to report onsite to the Home Office for business meetings as needed. The successful candidate will also be required to travel as needed throughout Alliance catchment area and surrounding counties (including ones outside of Alliance’s catchment area) to meet with members, providers, attend court hearing, and/or other community stakeholders.

Responsibilities & Duties

Audit/Post-Payment Reviews/Prepayment Reviews

• Conduct routine and targeted post-payment and prepayment audits of Medicaid and State funded providers to ensure that services are rendered and documented in accordance with established state and federal rules, regulations, policies, and terms of provider contractual agreements with the state
• Develop audit plans and tools based on the services to be audited
• Request and/or collect medical records, personnel records, policies/procedures, compliance plans, and other documents from providers based on audit plans
• Systematically and accurately collect, document, and store evidence
• Identify inappropriate billing and improper payments
• Document audit activities and findings in a detailed report
• Present audit results to leadership and Compliance Committee
• Attends appeal hearings to present and explain review findings

Provider Enrollment Due Diligence Reviews

• Conduct reviews of newly enrolled providers to ensure eligibility, qualifications, and/or licensure requirements are met per state and federal rules, regulations, policies, and terms of provider contractual agreements with the state

Regulatory Review/Research

• Diligently research clinical policies, administrative code, federal/state laws to assess for noncompliance

Data Analytics

• Analyze data from a variety of sources, including but not limited to claims, authorizations, enrollment, grievances, prior audits/investigations, incident reports, policies/procedures, to inform decision making
• Utilize various Strategy and Healthcare Fraud Shield reports data during the audit process

Technical Assistance/Education

• Educates providers on the errors identified in the audit process
• Recognize when providers can improve through technical assistance (TA) rather than formal corrective action
• Recognize quality of care issues and make recommendations to appropriate entities/authorities

Provider Action and Follow-Up

• Document Improper Payment Charts, Statements of Deficiency, provides feedback and technical assistance to providers as needed/requested, and follows up on provider corrective action, as applicable
• Prepare for and participate in provider appeal process and/or court hearings to explain and defend audit findings

Travel

• Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc. may be required
• Travel to meet with members, providers, stakeholders, attend court hearings etc. is required

Minimum Requirements

Education & Experience

Bachelor’s degree in health care compliance, analytics, government/public administration, auditing, security management, criminal justice, or pre-law, from an accredited College/University and three (3) years of post-degree of experience in healthcare compliance, regulatory analysis, policy development, auditing, investigations, accreditation or any equivalent combination of related training and experience.

Preferred:

• Health care industry and/or Medicare/Medicaid/Behavioral Health knowledge
• Certification from AHFI, CFE, CPMA, CPC, CHC, or equivalent
• CLEAR Certified Investigator (Basic and Specialized)
• Clinical license as an LCSW, LCMHC, LMFT, LCAS, or LPA

Knowledge, Skills, & Abilities

• Knowledge of the Alliance Health service benefit plans and network providers
• Knowledge of Health care industry and/or Medicare/Medicaid/Behavioral Health knowledge
• Knowledge of the state and federal Medicaid laws, state and federal criminal and civil fraud laws, regulations, policies, rules, guidelines, service limitations, and various Medicaid programs
• Knowledge and proficiency in claims adjudication standards & procedures
• A general understanding of all major MCO functions, in particular as it relates to prior authorization, utilization reviews, grievance management, provider credentialing and monitoring
• High degree of integrity and confidentiality required handling information that is considered personal and confidential

Salary Range

$33.46- $42.66/Hourly

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity

An excellent fringe benefit package accompanies the salary, which includes:

• Medical, Dental, Vision, Life, Long Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility

Education

Required

• Bachelors or better in Human Services
• Bachelors or better in Social Service
• Bachelors or better in Analytics
• Bachelors or better in Public Administration
• Bachelors or better in Auditing
• Bachelors or better in Security Management
• Bachelors or better in Pre-Law
• Bachelors or better in Criminal Justice

Licenses & Certifications

Preferred

• Acc Hlthcare Fraud Invest
• Certified Fraud Examiner
• Cert-Healthcare Complianc
• Certified Prof Coder
• Lic Clin Addiction Spec
• Lic Clinical MH Counselor
• Lic Clinical Social Wkr
• Lic Marr & Family Ther
• Lic Psychological Assoc

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.