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

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