Remote Senior Medicaid Program Integrity Consultant

BerryDunn — Assurance, Tax and Consulting

United States

Hybrid

USD 85,000 - 100,000

Full time

14 days+

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Benefits offered by this job

Travel opportunities

Flexible location

Job summary

BerryDunn is seeking a Senior Consultant with subject matter expertise in Medicaid program integrity and claims audits to support Hawaiʻi MQD's Medicaid Program Integrity initiatives as a forensic analyst. You will perform claims audits, document findings, and conduct forensic reviews and investigations related to Medicaid claims and related data.

Travel approx. 30–50% with onsite meetings and go-live activities.

Qualifications

Minimum three (3) years of experience conducting Medicaid claims audits, investigations, and/or compliance reviews.
Knowledge of Medicaid Program Integrity principles, FWA, provider oversight, payment integrity, TPL, claims audit, or cost avoidance concepts.
Experience developing or supporting audit findings, corrective action plans, executive-ready reporting, analytical summaries, methodology documentation, quality checks, or recurring performance reports.
Strong analytical, documentation, quality assurance, and stakeholder coordination skills.
Experience using SharePoint, Microsoft Teams, Outlook, Excel, or comparable tools to manage action items, documentation, investigative follow-up, and project coordination.
Bachelor’s degree or equivalent combination of education and applicable experience preferred.
Ability to conduct research and analysis related to Medicaid policies, claims, provider oversight, payment integrity, and program integrity requirements.
Ability to handle sensitive program, operational, provider, member, client, PII/PHI, and HIPAA-related information in alignment with confidentiality and data security expectations.

Responsibilities

Conduct detailed reviews of Medicaid claims and related provider, member, eligibility, financial, and operational data to identify, document, and elevate potential fraud, waste, abuse, improper payments, compliance issues, and operational risks.
Review Medicaid claims for accuracy, compliance, reasonableness, and alignment with Medicaid policies, federal and state regulations, program requirements, and coding standards and guidance.
Support the review of operational data related to provider management, member services, financial management, and TPL.
Prepare audit and investigative documentation such as case summaries, findings, recommendations, workpapers, and supporting materials for review by the Forensic Manager, Program Integrity staff, audit SMEs, and project leadership.
Research, interpret, and apply Medicaid policies, program integrity requirements, and applicable regulations to support audit findings, investigative documentation, recommendations, and corrective action follow-up.
Assist with development of controls, monitoring approaches, review protocols, audit tools, documentation standards, and process improvements to strengthen FWA detection and deterrence.
Support development or updates to policies, procedures related to Medicaid program integrity.
Assist in the development of training, knowledge transfer, and technical assistance for client staff related to program integrity.
Use Jira, SharePoint, meeting notes, decision logs, and action item trackers to support transparent issue tracking, documentation, coordination, and follow-through across workstreams.
Support onsite planning, workgroup sessions, client leadership preparation, release activities, and related project needs in coordination with the Forensic Manager, project leadership, and workstream leads.