Medicaid Payment Integrity Subject Matter Expert

Responsibilities:

• Manage forensic review, investigative, and provider audit activities related to Medicaid medical, dental, behavioral health, pharmacy claims, as well as provider, member, financial, audit, TPL, and operational data.
• Lead identification, documentation, and escalation of potential fraud, waste, abuse, or non-compliance risks, and review Medicaid claims for accuracy and compliance with policies.
• Provide oversight and coordination for forensic analysts, audit SMEs, and team members, and develop corrective action recommendations.

Qualifications:

• Minimum five years of experience leading Medicaid payment/program integrity initiatives and managing provider audits, with in-depth understanding of medical coding and claims processing.
• Experience with Jira, SharePoint, Microsoft Teams, Outlook, Excel, or similar tools for coordination and documentation.
• Preferred: Relevant certifications such as CPC, CHC, CPMA, CFE, or CIA.