Program Integrity Auditor (HCPS/DAIO)

Program Integrity Auditor (HCPS/DAIO) 71029001 This Health Care Program Specialist functions as an auditor and helps ensure that fraud, waste, and abuse is identified and improper payments are recovered. This position offers the flexibility to create your own audit approach and focus. Do you have a natural affinity and passion for problem solving? Are you looking for work life balance, great benefits and stability? This might be the right fit for you! All HCA employees will apply an equity lens to their work, which may include but is not limited to all analyses of core business and processes. About the division: The Division of Audit, Integrity, and Oversight (DAIO) is responsible for providing oversight and helping ensure the integrity of our healthcare purchasing and grant activities. This includes auditing medical and other benefit providers and beneficiaries; the identification, prevention, and investigation of fraud, waste, and abuse; grant subrecipient monitoring; managed care organization contract monitoring; PEBB/SEBB monitoring; and the oversight of behavioral health and recovery spending. About the position: This position serves as an auditor in the Audit, Investigation, and Monitoring unit. It conducts research and data analysis of provider utilization profiles; and audits, reviews, and investigates Apple Health healthcare providers to identify potential fraud, waste and abuse and recover related-improper payments, and refers credible allegations of fraud and quality of care/licensing issues to the appropriate authority. Through these program integrity efforts, the position supports the HCA’s mission to “Provide high quality health care through innovative health policies and purchasing strategies.” This position is eligible to telework, however, may be required to report on-site periodically. Minimal travel may be required to attend training, conferences, or events. The default assigned work location of all Health Care Authority (HCA) positions – both on-site and telework eligible positions – is within the State of Washington. This position reports to Olympia, WA. Frequency of onsite work will vary based on business and operational needs. All agency employees are required to report on-site in Olympia on their first and last days of employment to pick up and return state-issued equipment, regardless of telework status or location. Some of what you will do:

• Plan and conduct reviews and audits of Apple Health provider claims to determine compliance with associated federal and state regulations; agency rules, policies and billing guides; and contracts or agreements.
• Use data analytics to identify risk patterns and outliers that could represent potential fraud, waste, or abuse.
• Document the audit results identifying any improper payments with conclusions based on rule, policy and billing instructions.
• Preparing professional audit reports summarizing the results.
• Represent HCA in providing expert testimony to explain and defend audit findings throughout the informal dispute process and the formal appeal process.
• Provide provider education throughout the audit process and participate in educational presentations.
• Providing technical assistance concerning the interpretation of health care policy and procedures, program analysis, and monitoring and improvement activities.
• Identify areas in the Washington Apple Health Provider Guides and other rules that could be strengthened to clarify and improve provider compliance.

Required qualifications: Qualifying candidates will meet one of the following criteria options: Option 1:

• Master’s degree with a major study in public health, public or business administration, auditing, or a related field.
• Two (2) years of experience in health services, including but not limited to direct services to clients, claims review or authorization, and business operations, or professional auditing.

Option 2:

• Bachelor's degree with a major study in public health, public or business administration, auditing, or a related field.
• Four (4) years of experience in health services, including but not limited to direct services to clients, claims review or authorization, and business operations, or professional auditing.

Option 3:

• Eight (8) years of experience in health services, including but not limited to direct services to clients, claims review or authorization, and business operations, or professional auditing.

Option 4:

• One year as a Health Care Program Consultant in State Government with duties and responsibilities in a supervisory or consultative capacity in health services, social services or Medicaid programs, including audits or reviews of healthcare claims

Required Knowledge, Skills, and Abilities:

• The ability to take action to learn and grow.
• The ability to take action to meet the needs of others.
• Detail-oriented with the ability to understand the nuances and variables of data.
• An objective mindset and a demonstrated ability to apply sound criteria in reaching fact-based conclusions.
• Demonstration of clear, effective oral and written communication skills.
• Demonstration of the ability to gather information from a variety of resources. Condense content and produce comprehensive, informative reports.
• Proficient in the use of Microsoft software, including Word and Excel.

Preferred qualifications:

• Working knowledge of medical terminology and interpretation of health care documentation.
• Knowledge of healthcare auditing concepts and principles.
• Working experience conducting medical record reviews and ability to interpret and apply Federal and State regulations, coding and billing requirements.
• Demonstrated experience in data mining, data interpretation, and data analysis.
• Knowledge of current and developing trends in medical healthcare delivery and billing.

How to apply: Only candidates who reflect the minimum qualifications on their NEOGOV profile will be considered. Failure to follow the application instructions below may lead to disqualification. To apply for this position, you will need to complete your profile which includes three professional references and attach them in separate files:

• A cover letter that specifically addresses how you meet the qualifications for this position
• Current resume

To take advantage of veteran preference, please do the following:

• Attach a copy of your DD214 (Member 4 long-form copy), NGB 22, or USDVA signed verification of service letter.
• Please black out any PII (personally identifiable information) data such as social security numbers. Include your name as it appears on your application in careers.wa.gov.

About HCA: Functioning as both the state's largest health care purchaser and its behavioral health authority, the Washington State Health Care Authority (HCA) is a leader in ensuring Washington residents have the opportunity to be as healthy as possible. There are three pillars of our work: Apple Health (Medicaid); the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs; and behavioral health and recovery. Under these pillars, HCA purchases health care, including behavioral health treatment for more than 2.7 million Washington residents and provides behavioral health prevention, crisis, and recovery supports to all Washington residents. What we have to offer:

• Meaningful work with friendly co-workers who care about those we serve Voices of HCA
• A clear agency mission that drives our work and is person-centered HCA's Mission, Vision & Values
• A healthy work/life balance, including alternative/flexible schedules and mobile work options.
• A great total compensation and benefit package WA State Government Benefits
• A safe, pleasant workplace in a convenient location with restaurants, and shopping nearby.
• And free parking!

Notes: Prior to a new hire, a background check including criminal record history will be conducted. Information from the background check will not necessarily preclude employment. HCA is an equal opportunity employer. We value the importance of creating an environment in which all employees can feel respected, included, and empowered to bring unique ideas to the agency. HCA has five employee resource groups (ERGs). ERGs are voluntary, employee-led groups whose aim is to foster a diverse, inclusive workplace aligned with HCA’s mission. Our diversity and inclusion efforts include embracing different cultures, backgrounds and viewpoints while fostering growth and advancement in the workplace. Studies have shown women, racial and ethnic minorities, and persons of disability are less likely to apply for jobs unless they feel they meet every qualification as described in a job description. Persons over 40 years of age, disabled and Vietnam era veterans, as well as people of all sexual orientations and gender identities are also encouraged to apply. If you have any questions about the required qualifications or how your experience relates to them, please contact us at [email protected]. Persons with disabilities needing assistance in the application process, or those needing this job announcement in an alternative format may contact Angelic Matthews at [email protected] The Washington State Health Care Authority (HCA) is an E-Verify employer. All applicants with a legal right to work in the United States are encouraged to apply. E-Verify® is a registered trademark of the U.S. Department of Homeland Security. Subscribe to our weekly newsletter to receive a list of new job postings at HCA. Apply tot his job Apply To this Job