Company Name:
Beacon Health Options
Approximate Salary:

Location:
BOSTON, Massachusetts
Country:
United States
Industry:
Healthcare
Position type:
Unspecified
Experience level:
Education level:

PROGRAM INTEGRITY AUDITOR I



Location
MA: Boston (1000 Washington St.)

Job Family
Legal & Compliance

Job Brief
PROGRAM INTEGRITY AUDITOR I will detect, investigate, remediate and refer to law enforcement as appropriate incidents of provider fraud, waste and abuse arising in connection with healthcare services.

Exempt

Weekdays Only

ABOUT THE POSITION

We are currently seeking a dynamic PROGRAM INTEGRITY AUDITOR I to join our team at our office in BOSTON, MA. The PROGRAM INTEGRITY AUDITOR I will detect, investigate, remediate and refer to law enforcement as appropriate incidents of provider fraud, waste and abuse arising in connection with healthcare services. Responsible for program integrity provider audit procedures and assisting in the implementation of the National Program Integrity Plan and related activities under the direction of the Director, National Program Integrity. Operates as a primary resource for Beacon Health Options (Beacon) and contact for fraud, waste and abuse investigation and prevention, provider monitoring and provider audit related activities.

Position Responsibilities:
  • Audit provider records to ensure they are documented and maintained to meet regulatory and contractual requirements and to identify any improper/potentially fraudulent, wasteful or abusive billing practices.Work with providers to develop corrective actions, including repayment of identified recoveries.
  • Write audit/investigative reports summarizing evidence, audit activities, and findings.This includes compiling and organizing accurate case file documentation and calculation of overpayments.Make referrals of findings to clients, regulators, and/or law enforcement as appropriate and directed by the Director, National Program Integrity.
  • Conduct data mining activities and analyze reports to detect potential fraud, waste, and abuse, and other outliers for further investigation.
  • Assist the Director, National Program Integrity with quarterly risk assessments and other required reporting.
  • Offer training and technical direction for providers and assist the Director, National Program Integrity in the identification of training needs.
  • Participate on special projects, committees, and task forces and perform other duties as assigned.
  • Foster and maintain positive relationships with representatives of Beacon's core functions, policyholders, law enforcement, clients, providers, and the general public.
  • Serves as a role model for compliant behavior and integrity, consistent with the mission, vision and values of Beacon, and as an internal authority on applicable audit standards.
  • Serve as Beacon's representative during formal proceedings when necessary.


Position Requirements:
  • : Audit provider records to ensure they are documented and maintained to meet regulatory and contractual requirements and to identify any improper/potentially fraudulent, wasteful or abusive billing practices. Work with providers to develop corrective actions, including repayment of identified recoveries.
    Certifications: Preference will be given to candidates with certifications related to their professional training, to include: Association of Certified Fraud Examiners (CFE); Accredited Healthcare Fraud Investigator (AHFI); Certified Internal Auditor (CIA); or Professional Coding through AAPC (CPC) (CPC-H) CPC-P) or AHIMA (CCS) (CCS-P).
  • Relevant Work Experience: Minimum of three years of experience in healthcare, accounting (public or private), or healthcare coding and auditing, with preference given to candidates with this experience in a managed care environment. In addition, at least two years of experience is required in fraud and abuse and/or white collar crime investigations and two to three years of experience in healthcare claims preferred.

Knowledge, Skills & Abilities:
  • Strong auditing and analytical skills, as well as knowledge of fraud investigative procedures, healthcare coding, medical record documentation requirements and judicial processes relating to fraud prosecutions.
  • Knowledge of the Massachusetts MassHealth program.
  • Knowledge of Medicaid and Medicare regulations.
  • Excellent communication, negotiation and conflict resolution skills.
  • Strong technical and business writing skills demonstrating the ability to write reports and business correspondence and to prepare case files.
  • In-depth knowledge of the healthcare industry; fraud, waste and abuse audit operations, and claims handling and payment operations.
  • Ability to interact with others in one-on-one situations to identify issues/problems and provide training/coaching to correct problem areas.


TO APPLY

Click below on "Apply for this Position" to create a profile and apply for the position

Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled

AAP Reporting Location:

MA - Boston (Corporate)

ID (Req #):

53209

FTE Status:

Full time

Schedule:

8:30am - 5:00pm



PI100430062