Job Summary:Works with a team of internal and external professionals by performing as a subject matter expert, relying on experience, education, research, and collaboration to produce program integrity and fraud vulnerability reports.
Essential Functions:- Participates in the planning and execution of team projects, assisting with setting strategic goals, defining project scope, and ensuring alignment with organizational objectives and customer needs.
- Implements processes and uses the necessary tools, integrating best practices to enhance project execution and drive consistent performance improvements.
- Conducts research of program areas/topics defined by management to include research of government reports, rules, and regulations as they relate to defined areas/topics; participates in internal and external focus groups, as required.
- Utilizes experience and expertise to identify the appropriate reports, rules, and regulations to be used in drafting vulnerability reports.
- Meets regularly with teams or working groups to discuss current and future projects; advises teams and management on topic areas and potential methods to use in conducting research.
- Contributes to the final written product that is presented to stakeholders; proofreads written products of other team members.
- Serves as a productive member of the external and internal teams in ensuring that all deadlines for deliverables are met. Briefs management on projects to include completion timelines and potential difficulties that may impact meeting deadlines.
- Provides clinical input as a Subject Matter Expert for program integrity and program vulnerability.
- Identifies and mitigates risks proactively, implementing strategies to address potential project obstacles and ensure the continuity of project execution.
- Participates in project reporting and performance analysis, ensuring that project data is accurate, and relevant.
Level of Supervision Received:Plans and arranges own work; works with manager to prioritize projects.
Education (can be substituted for experience):Bachelor's Degree required
Work Experience (can be substituted for education):5 - 7 years required; 8 - 11 years preferred
RN preferred
Experience in Medicaid coding, billing, auditing, and compliance from a state or federal perspective.
Medicaid program integrity auditing experience is preferred.
Experience locating and interpreting publicly available Medicaid information to identify relevant potential program vulnerabilities.
