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Healthcare Auditor

Employer
University of Massachusetts Medical School
Location
529 Main Street

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Administrative Jobs
Technology, Analysts & Programming
Employment Type
Full Time
Institution Type
Four-Year Institution
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Job Details

Overview

GENERAL SUMMARY OF POSITION:

Under the general direction of the Associate Director or designee, the Program Auditor serves a crucial role in combating fraud, waste and abuse (FWA) within the Medicaid program.  A major function of this position is to conduct desk and onsite reviews based on federal and state regulations that govern provider types.  Audits involve extensive research to identify industry trends and patterns in order to detect aberrant billing practices.  Working independently, or within a team, the Auditor performs all activities related to data mining, claims analysis, and auditing. The auditor will participate in face to face entrance and exit conferences with providers utilizing established interviewing skills.

Responsibilities

MAJOR RESPONSIBILITIES:

  • Apply in-depth knowledge of federal and state regulations and healthcare industry standards.
  • Conduct independent data mining and data analysis utilizing claims data to identify potential cases of FWA.
  • Conduct onsite audits which may include a review of the physical plant, member medical records, and employee records.
  • Conduct audit entrance and exit conferences with providers as well as interview provider staff.
  • Develop reports of investigative findings, compile case file documentation, calculate sanctions and overpayments, and issue findings in accordance with applicable regulations, policies and procedures.
  • Document work performed and audit results based on pre-determined standards and guidelines.
  • Communicate with providers regarding issues such as general regulatory compliance, audit findings, and the recovery process.
  • Identify and recommend policy, procedure and system changes to enhance investigative outcomes and performance.
  • Serve as a resource for internal and external departments to research and resolve integrity inquires.
  • Update appropriate internal management staff regularly on progress of investigations and make recommendations for further initiatives such as new algorithms.
  • Exercise independent judgment and discretion in using available resources to identify relevant evidence supporting allegations.
  • Prepare internal and external reports.
  • Develop, maintain and manage cases in internal case tracking system.
  • Perform other duties as assigned.
Qualifications

REQUIRED QUALIFICATIONS:

  • Bachelor’s degree in business administration, finance or related field; or equivalent experience
  • 6-8 years of related experience in the healthcare industry, business, accounting or finance; with at least two years of experience conducting data mining in the healthcare insurance industry, healthcare claim audits or other claims related experience.
  • Knowledge of the principles and practices of medical auditing.
  • Strong analytical and qualitative skills as well as problem solving skills with the ability to look for root causes and implement workable solutions.
  • Knowledge of the law and regulations as it relates to fraud and fraud investigations.
  • Must have a track record of producing high quality work that demonstrates attention to detail.
  • Ability to multi-task, establish priorities and work independently to achieve objectives.
  • Ability to function effectively under pressure.
  • Proficiency in Microsoft Office applications (Word, Excel, PowerPoint and Access).
  • Excellent Customer service skills with the ability to interact professionally and effectively with providers, third party payers, and staff from all departments.
  • Strong Interpersonal skills with the ability to work in a fast paced environment whether as a team member or an independent contributor.
  • Strong oral and written communication skills including internal and external presentations.
  • Ability to travel and be on-site as needed for audits.

 

PREFERRED QUALIFICATIONS:

  • Master’s degree in Business Administration or Public Health.
  • Knowledge of coding, reimbursement and claims processing policies.
  • Prefer individual possessing any of the following certifications or licensure: CFE, CPA, RN/LPN, CPC, or CPMA.  
  • Advanced Microsoft Excel software skills.
  • Knowledge of State and federal regulations as they apply to public assistance programs.
  • Strong Decision making skills with the ability to investigate and weigh alternatives and select the appropriate course of action.
  • Creative thinking skills with the ability to ask the needed “bigger- picture” questions that lead to process and team improvements.

Organization

Realize Your Opportunities – A Career at UMASS Medical School

Inside Workings at UMASS Medical School

The University of Massachusetts Medical School (UMMS), the Commonwealth's only public medical school, is proud of our role in serving the people of Massachusetts. Although, its the inside workings of UMMS that makes the difference.

Mission and Culture

  • We’re serious about our mission and about our people. 
  • Real World Impact - Our people get excited about our mission of real-world impact in health sciences education, research and public service.
  • International Prominence and New Opportunities - As this institution has grown to national – and international – prominence, we’ve found new opportunities to train tomorrow’s physicians, nurses and scientists,  discover causes of and cures for disease and help improve the quality of health care.
  • Deep Commitment - With our clinical partner, UMass Memorial Health Care, and our other teaching affiliates, we share a deep commitment to national distinction in patient care.
  • Valued Partnerships – UMMS partners with Commonwealth Medicine, the health care consulting arm of UMMS. Also, UMMS partners with MassBiologics in scientific collaborations, technology management and creating partnerships for the development of products for the benefit of patients.  These valued partnerships help us to provide services and programs to help meet our needs at UMMS and the public.
  • Proud Contributors - People at UMMS enjoy the feeling of going to work every day knowing what they do is truly important and worthwhile.
  • Complementary and Inseparable - These varied parts of our mission and culture are complementary and inseparable.                 

Careers

UMMS, the state’s first and only public academic health sciences center, educates physicians, scientists and advanced practice nurses to heal, discover, teach and care, with compassion.  UMMS is a world-class institution with opportunities to match. 

Competitive Compensation – UMMS offers salaries that are competitive with Worcester-area employers. When combined with our generous benefits, perks, and paid time off, many job seekers are surprised to find a total rewards package that matches or exceeds their current situation.

Targeted Hiring Process – At UMMS, there are actually multiple hiring processes for different segments of our workforce.  In nearly all cases, UMMS hiring process is decentralized, with qualified candidates screened and referred to an academic officer or manager with hiring authority.

24/7 Access to Employment Opportunities – iCIMS is our online job search and application system.  iCIMS is available 24/7 to provide you with a convenient and up-to-date view of the available employment opportunities across our campuses. Updates are made daily and include all faculty and non-faculty position listings from every school and department within the UMMS. When you identify a position you are interested in and qualified for, apply online. New opportunities become available frequently so it pays to check back often!

Benefits

With outstanding benefits, competitive pay, extensive learning opportunities, and a stimulating and attractive work environment, UMMS may be exactly the employer you’ve been looking for.

• Superior Benefits - UMMS offers a wide range of benefits and perks that invite comparison with the best employers in the Worcester area – and with academic institutions anywhere. UMMS provides superior medical and dental coverage for you and your family, fully funded retirement plans, generous time off, a Tuition Assistance Plan – and much more.

• People Centered - UMMS is an employer, but it is also a community. Its comprehensive medical and dental benefits, retirement plans, and even paid holidays reflect an institution built around people, with a deep respect for their differences and needs.

• Commitment to Healthy Living - UMMS provides resources to help you balance work and life and encourages healthy living through great programs and discounts for fitness, physical activity, weight management, nutritional counseling and general wellness available through our health insurance plans.

• Breadth of Offerings - Above all, the breadth of UMMS offerings set the School apart and makes it an environment favored by all sorts of smart, career-savvy people.

Apply for a Job

As an equal opportunity and affirmative action employer, UMMS recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds.

Online - To view all job opportunities and apply online, visit www.umassmed.edu/hr and click on the “Careers” tab.

Start Now and Realize Your Opportunities!

A History of Making Vital Improvements - UMASS Medical School Milestones

1962: Legislation establishes University of Massachusetts Medical School
1970: First medical students begin classes in Shaw Building
1974: First class graduates 16 MDs
1979: PhD program begins
1986: Graduate School of Nursing opens
1986: PhD program becomes Graduate School of Biomedical Sciences
1994: Graduate School of Nursing initiates PhD program
1998: UMass Clinical System and Memorial Health Care merge to form UMass Memorial Health Care
2001: Lazare Research Building opens
2002: Campus Modernization begins on the University Campus
2004: Graduate Entry Pathway Program established at the Graduate School of Nursing
2005: PhD Program in Clinical & Population Health Research established at the Graduate School of Biomedical Sciences
2005: Massachusetts Biologic Laboratories opens new manufacturing and filling facility in Mattapan
2006: Craig Mello, PhD, Blais University Chair in Molecular Medicine and Howard Hughes Medical Institute Investigator, is awarded the Medical School's first Nobel Prize. Dr. Mello shared the 2006 Nobel Prize in Physiology or Medicine with Andrew Fire, PhD, of Stanford University, for their discoveries related to RNA interference.
2007: Michael F. Collins, MD, is named chancellor and Terence R. Flotte, MD, is named dean of the School of Medicine.  
2009: Groundbreaking for the Albert Sherman Center, a 500,000-square-foot research and education facility slated for completion in 2012.
2010: Ambulatory Care Center opens
2012: The Albert Sherman Center, a 500,000-square-foot research and education facility, completed and opens

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