Senior Medical Audit Specialist

State of Oklahoma; Oklahoma; On-site; USD 67,000 - 90,000; Full time

Job summary

State of Oklahoma, Oklahoma Health Care Authority, is seeking a Senior Medical Audit Specialist to provide clinical expertise in audits, investigations, and compliance with state and federal regulations. The role focuses on safeguarding billing integrity and working with internal and external stakeholders to ensure accurate reimbursement.

The position requires an active RN license with 5+ years of nursing experience, and preferred certifications in medical auditing.

Qualifications

• RN licensure is required with no substitutions for licensure.
• 5+ years of professional nursing experience required.
• Certifications in medical auditing (CPMA/CPC) preferred.
• Experience with Medicaid/Medicare billing audits and medical reviews is a plus.

Responsibilities

• Provide clinical expertise in investigations and audits to detect fraud, waste, and abuse.
• Ensure billing compliance with OHCA policy, state statutes, and federal regulations.
• Analyze billed services and documentation to verify alignment with policy and clinical appropriateness.
• Communicate audit findings to stakeholders and participate in relevant hearings or proceedings.

Skills

Clinical expertise

Billing analysis

Communication skills

Collaboration

Education

RN licensure (RN)

5+ years nursing experience

Job description

Job Posting End Date

Refer to the date listed at the top of this posting, if available. Continuous if date is blank.

Job Posting Title

Senior Medical Audit Specialist

Agency

807 HEALTH CARE AUTHORITY

Supervisory Organization

Program Integrity & Account

Job Posting End Date

Refer to the date listed at the top of this posting, if available. Continuous if date is blank.

Note: Applications will be accepted until 11:59 PM on the day prior to the posting end date above.

Full/Part-Time

Full time

Job Type

Regular

Compensation

$78,465.00/annual

Why You’ll Love Working Here

At the Oklahoma Health Care Authority (OHCA), your work matters. Every day, our team helps ensure Oklahomans have access to better health and better care. Guided by our core values, Passion for Purpose, Trust & Transparency, Empowerment & Accountability, Best-in-Class, Outcome-Driven, and Servant Leadership, we foster a workplace where people feel supported, respected, and empowered to make an impact. Learn more about OHCA.

Let’s Talk Benefits

We know your great work deserves great support. Here’s a snapshot of what we offer for all eligible employees.

• Generous state-paid benefit allowance to offset insurance premiums.
• A wide selection of insurance plans with no pre-existing condition exclusions.
• Flexible Spending Accounts for health care and dependent care.
• Retirement Savings Plan with employer contributions.
• 11 paid holidays annually.
• 15 days of vacation and 15 days of sick leave in the first year.
• Longevity Bonus recognizing years of public service.
• Public Service Loan Forgiveness eligibility and tuition reimbursement.
• Wellness benefits, including an on-site gym and fitness center discounts.

Job Description

Location: 4345 N Lincoln Blvd, Oklahoma City, OK 73105

Salary: $78,465.00/annual

Work Schedule: Monday – Friday

Primary Hours: 8:00 a.m. – 5:00 p.m.

Agency/Division Information

The Oklahoma Health Care Authority (OHCA) works to ensure Oklahomans have access to better health and better care. The agency’s core values include passion for purpose, trust and transparency, empowerment and accountability, best in class and outcome-driven, and servant leadership. As part of the interview process, candidates may be required to attend an in-person interview at our Oklahoma City office.

Position Purpose

The Senior Medical Audit Specialist plays a critical role in safeguarding the integrity of healthcare services by providing clinicalexpertisein conducting audits and investigations to combat fraud, waste, and abuse. This position ensures compliance with OHCA policies, state statutes, and federal regulations through detailed analysis of billed services and documentation. By collaborating with internal and external stakeholders, the Senior Medical Audit Specialist helps to promote accountability and transparency in billing practices, supporting the overall mission of the Oklahoma Health Care Authority to provide better health and care for Oklahomans.

Essential Functions May Include

• Provide clinicalexpertisein conducting investigations and completing comprehensive clinical auditsin an effort tocombat fraud, waste, and abuse.
• Ensure billingcompliance with OHCA policy, state statutes, and federal regulations.
• Performs analysis and evaluation of billed services including claims and documentation to ensure all HCA policy requirements are met and services are clinically/medicallyappropriate.
• Collaborate with others across the unit, organization, and external entities to evaluate audit results and make referrals to appropriate parties.
• Communicate audit findings to all stakeholders.
• Representsthe Provider Audits Unit before an Administrative Law Judge (ALJ) and in legal proceedingsregardingany general provider appeals, in an informed and professional manner.
• Maintain licensure and certifications.
• Other duties as assigned.

Supervisory Responsibilities

This position does not supervise.

Knowledge, Skills, Abilities And Competency Requirements

The Senior Medical Audit Specialist requires in-depth knowledge of healthcare policies, state and federal regulations, and audit processes, as well as the ability to analyze complex billing data and ensure compliance.Strong communicationand collaboration skills are essential to effectively convey audit findings and work with various stakeholders. This role demands strategic problem-solving and organizational skills to manage multiple tasks and resolve complex issues.

The best-fitting Korn Ferry competencies for this position includeEnsures Accountability, as the role focuses on enforcing compliance and managing responsibilities, andCollaborates, given the need for cross-functional teamwork and stakeholder engagement.

• To be considered for this position your application must include a resume/CV with complete work and education history.

Education And/or Experience

• Possession of a valid permanent Oklahoma license as a Registered Nurse (RN) as approved by the Oklahoma Board of Nursing or Registered Nurse License recognized by the Enhanced Nurse Licensure Compact (eNLC) AND
• 5 years of professional experience as a registered nurse.
• There is no substitution for licensure.

Preference Qualifications Include

• Certifications in any of the followingareas:Certified Professional Medical Auditor (CPMA),Certified Professional Coder (CPC)
• General understanding of codingprinciples(CPT, HCPCS, ICD-10 and /or DRG)
• Experience with Medicaid and Medicare billing audits
• Experience in medical review, auditing,utilizationreview,complianceor regulatory work.

Physical Demands and Work Environment

Work is typically performed in an office setting with climate-controlled settings and exposure to moderate noise levels. In the course of performing job duties, employees are required to speak, stand, walk, and reach with their hands and arms. This position requires extended periods of sitting and daily use of computers and phones. Employees must be willing to complete all job-related travel associated with this position. Being present at the office is an essential function of this position.

Accommodation Statement

The Oklahoma Health Care Authority complies with applicable State and Federal civil rights laws and does not discriminate. All qualified applicants will receive consideration for employment without regard to race, color, sex, religion, disability, age, national origin, or genetic information. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact the Civil Rights Coordinator at 405-522-7335.

Equal Opportunity Employment

The State of Oklahoma is an equal opportunity employer and does not discriminate on the basis of genetic information, race, religion, color, sex, age, national origin, or disability.

Current active State of Oklahoma employees must apply for open positions internally through the Workday Jobs Hub.