Program Integrity (MCU) - Coordinator 2 na State of Louisiana, LA
State of Louisiana, LA · Baton Rouge, Estados Unidos Da América · Onsite
- Professional
- Escritório em Baton Rouge
Other Qualifications
•Assess Managed Care Entity (MCE) compliance with contract deliverables.
•Review and assess fraud, waste, and abuse (FWA) investigation reports, referrals, and tips from MCEs.
•Identify and investigate audit leads and risk areas within the Medicaid program.
•Plan and perform all phases of desk and on-site reviews of provider or MCE facilities. Includes selecting an audit sample, inspecting/assessing facilities, obtaining records necessary to conduct a thorough and complete investigation, and conducting interviews with the health plan or provider and staff.
•Prepare case documents, audit summaries, and reports.
•Coordinate law enforcement requests, managed care investigations, external audit requests, referrals, tips, and complaints with MCEs, MFCU, and other Program Integrity staff.
•Maintain case lists, investigation documents, Program Integrity policies and procedures, written communications and directives sent to MCEs, and other programmatic documentation as requested.
•Recommend appropriate sanctions or corrective actions based on audit or investigation findings.
•Research and assist with MCE contract questions; recommend contract and policy changes as needed.
•Educate providers on appropriate billing and Medicaid policy, rules, and regulations.
•Assist with data mining and other special projects at the request of LDH Program Integrity staff.
•Assist with development of reports and data dashboards to enhance MCE oversight efforts.
•Assist co-workers with questions and/or issues that arise.
•Assist with MFCU/PI/MCE meetings and communications.
•Other duties as assigned.
Required Qualifications:
•Bachelor’s Degree.
•Minimum 1 year of professional experience in auditing, policy, data analysis, or claims monitoring/processing.
•Excellent analytical skills, effective organizational and time management skills.
•Great attention to detail and follow up.
•Ability to manage projects, assignments, and competing priorities.
•Proficient in the use of Microsoft Office, including but not limited to Outlook, Word, and Excel.
Desired Qualifications:
•Advanced degree.
•Minimum 2 years of professional experience in auditing, policy, data analysis, or claims monitoring/processing.
•Professional experience in government programs, healthcare, criminal justice, or accounting.
•Experience writing and conducting queries using SQL and/or SAS.
•CPT, ICD 10 coding and HCPCS knowledge.
•CHDA, HIM, RHIA, RHIT, CCA, CMA, CPA, CIA, CGAP, HFMA or other relevant industry certifications.
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