Remote Medicaid Payment Integrity Expert

BerryDunn — Assurance, Tax and Consulting; United States; Hybrid; USD 110,000 - 140,000; Full time

Job summary

BerryDunn seeks an experienced Senior Consultant with Medicaid program integrity expertise to support Hawaiʻi MQD and related initiatives. You will oversee forensic reviews, audits, investigations, and corrective action, coordinating with program integrity staff, data analysts, and vendor partners.

You will help interpret Medicaid policy, establish KPIs, and develop audit findings and documentation to support risk mitigation and recovery efforts. Travel up to 50% may be required.

Qualifications

• Five (5) years of experience leading Medicaid payment/program integrity initiatives and managing provider audits, overpayment identification, claims audits, and recovery activities.
• Deep understanding of medical coding (ICD-10, CPT), claims processing, and Medicaid requirements.
• Experience reviewing or auditing Medicaid data including medical, dental, behavioral health, pharmacy, provider, member, eligibility, TPL, or claims data.
• Experience managing forensic reviews, investigations, claims audits, or compliance reviews.
• Knowledge of Medicaid fee-for-service and managed care delivery systems, including encounter data, provider network management, and payment methodologies.
• Extensive knowledge of Medicaid Program Integrity, FWA, provider oversight, payment integrity, TPL, claims audit, or cost avoidance concepts.
• Experience developing audit findings, corrective action plans, executive-ready reporting, and methodology documentation.
• Strong analytical, documentation, quality assurance, and stakeholder coordination skills.

Responsibilities

• Manage forensic review, investigative, and provider audit activities related to Medicaid data and related systems.
• Provide oversight and coordination for forensic analysts, audit SMEs, and claims review resources.
• Lead identification and escalation of potential fraud, waste, abuse, or non-compliance risks.
• Review Medicaid claims and medical records for accuracy, reasonableness, and policy compliance.
• Interpret Medicaid policies and regulations to support audit findings and corrective actions.
• Establish and monitor program integrity objectives, metrics, and KPIs.
• Develop and review investigative documentation, case summaries, and recommendations.
• Support development of controls and process improvements to strengthen FWA detection.
• Create corrective action plans and follow-up procedures.

Skills

Medicaid program integrity

Forensic reviews

Audit management

Data analysis

Stakeholder coordination

Policy interpretation

HIPAA compliance

Jira/SharePoint/MS Teams

Education

Bachelor's degree or equivalent

Tools

Excel

SQL

Power BI

Tableau

Jira

SharePoint

Microsoft Teams

Outlook

Job description

BerryDunn seeks an experienced Senior Consultant with Medicaid program integrity expertise to support Hawaiʻi MQD and related initiatives. You will oversee forensic reviews, audits, investigations, and corrective action, coordinating with program integrity staff, data analysts, and vendor partners.

You will help interpret Medicaid policy, establish KPIs, and develop audit findings and documentation to support risk mitigation and recovery efforts. Travel up to 50% may be required.