Program Integrity Auditor
Core
Review medical, behavioral, and transportation provider records to ensure correct coding and appropriate documentation, identifying fraud, waste, and abuse (FWA) patterns.
Role type
Program Integrity Auditor (Healthcare Compliance)
Builds
Audit reports, regulatory deliverables, and FWA avoidance/detection plans for health plans serving Medicaid members.
Domain
Healthcare / Medical Billing & Compliance
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Claims data interpretation, Medical record review, CPT coding, HCPCS coding, ICD-10 coding, Regulatory compliance analysis, Billing pattern identification, Provider education, Audit documentation, State/federal requirement knowledge
Preferred skills
Medicaid/Health plan experience, AHCCCS experience, QuickBase proficiency, Critical thinking, Analytical skills, Attention to detail
Technologies
QuickBase, CPT, HCPCS, ICD-10
Responsibilities
Audit routine and ad hoc provider records for coding and documentation standards; Identify aberrant billing patterns and potential FWA; Coordinate audit documentation and reports for stakeholders; Assist with FWA avoidance and detection plans; Submit regulator deliverables; Provide technical assistance and training to providers on regulatory and coding rules.
Seniority
Mid-level, hands-on IC
