Compliance and Claims Auditor - R00000047028 DESCRIPTION/RESPONSIBILITIES:Responsible for conducting compliance audits, risk assessments, investigations, education and training assignments relating to billing, coding, reimbursement and documentations. At least sixty percent of the time involves working in the field with vendors, subcontractors and providers. Responsible for conducting claims and compliance audits for the purpose of detecting and/or recovering inappropriate benefit payments due to billing inaccuracies and/or abusive and fraudulent practices, as well as complying with state and federal regulatory compliance and fraud reporting requirements.* Conducts reviews of behavioral health consumers? medical record to assess whether covered behavioral health services delivered to the consumer and billed to Medicaid are accurate and appropriate.* Prepares detailed audit findings reports.* Tracks and trends compliance statistics and use to implement strategies to improve provider compliance.* Implements corrective action as necessary to ensure the highest levels of provider compliance.* Conducts re-audits of providers' medical records to verify corrective actions were fully implemented and effective.* Collaborates and work in coordination with other subject matter experts in Special Investigations Unit (SIU), cost containment, legal, claims, network, compliance and external county and federal and state regulatory authorities such as the Bureau of Program Integrity, Department of Public Welfare, Office of the Attorney General and others to identify, investigate and report overpayment, duplicative payment, false claims, abuse, and fraud situations and, as appropriate, assist in the process of recovery of overpayments.* Reviews and monitors provider compliance with Medicaid Licensing and billing requirements in all levels of Medical Assistance funded care.* Conducts provider and member interviews as a part of the overall review process.* Ensures providers have a compliance plan and policies and procedures that detail provider expectations.* Reviews, monitors and reports on providers' effective implementation of the plan.* Further develops comprehensive audit and monitoring tools, provider compliance plan expectations, provider training materials and reporting templates etc.* Provides technical assistance as needed.* Presents findings reports at designated meetings (i.e. internal, customer, provider, etc.)* Ensures compliance regarding HIPAA regulations and forward mandatory reports to designated recipients. Other compliance related duties as instructed. Other Job RequirementsResponsibilitiesKnowledge of Medicaid licensing and billing requirements, DSM-IV.Ability to collaborate with many functional areas of a national organization.Large and, at times, complex database management skills coupled with strong working knowledge of Excel.Knowledge of HIPAA.Healthcare experience. General Job InformationTitleCompliance and Claims Auditor Grade22 Work Experience - RequiredHealthcare Work Experience - Preferred Education - RequiredBachelors Education - PreferredMasters License and Certifications - Required License and Certifications - Preferred Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures. Equal Opportunity Employer-minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity
