SME - Medicaid Program Integrity and Claims Audits

Responsibilities:

• Conduct risk assessments, external audit coordination, and claims audits for medical, dental, behavioral health, and pharmacy.
• Develop or update policies and procedures, corrective action plans, and analyze program integrity reports.
• Provide quality assurance reviews and serve as a senior systems advisor for implementations.

Requirements:

• Bachelor's Degree or equivalent experience, with excellent communication and research skills.
• Medical claims billing or adjudication experience and knowledge of quality assurance procedures.
• Strong experience with Microsoft applications and artificial intelligence, with willingness to travel up to 50%.

Preferred Qualifications:

• Prior consulting experience, especially with state Medicaid agencies or government program integrity units.
• Experience with fraud risk assessments and internal audits, along with relevant professional certifications.