Senior Consultant – Medicaid Program Integrity

🔥 1 minute ago

🌺 Hawaii – Remote

🌺 Hawaii – Remote

💵 $85k - $100k / year

⏰ Full Time

🟠 Senior

💼 Consultant

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BerryDunn — Assurance, Tax and Consulting

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1974

🏥 Healthcare

🛡️ Insurance

⚖️ Legal

Healthcare • Insurance • Legal

BerryDunn is an award-winning accounting and consulting firm with a 50-year history dedicated to providing exceptional services in assurance, tax, and consulting. The firm focuses on forming close partnerships with clients to deliver customized solutions that drive meaningful outcomes. Its expert teams work across various sectors, helping public and private entities optimize finances, reduce risks, and improve business processes with a commitment to client success.

📋 Description

• Conduct detailed reviews of Medicaid claims and provider, member, eligibility, financial, and operational data • Identify, document, and escalate potential fraud, waste, abuse, improper payments, compliance issues, and operational risks • Review claims for accuracy, compliance, reasonableness, policy alignment, regulations, program requirements, and coding standards • Support reviews of provider management, member services, financial management, and TPL operational data • Prepare case summaries, findings, recommendations, workpapers, and supporting audit and investigative documentation • Research, interpret, and apply Medicaid policies, program integrity requirements, and regulations • Assist with controls, monitoring approaches, review protocols, audit tools, documentation standards, and process improvements • Support updates to Medicaid program integrity policies and procedures • Assist with training, knowledge transfer, and technical assistance for client staff • Use Jira, SharePoint, Microsoft Office, Teams, Outlook, and related Medicaid or vendor systems for tracking, documentation, coordination, reporting, and follow-through • Support onsite planning, workgroup sessions, client leadership preparation, release activities, and project needs • Collaborate with MQD staff, audit and TPL specialists, data analysts, compliance staff, vendor partners, and cross-functional workstream members

🎯 Requirements

• Minimum three (3) years of experience conducting Medicaid claims audits, investigations, and/or compliance reviews • Knowledge of Medicaid Program Integrity principles, fraud, waste and abuse, provider oversight, payment integrity, TPL, claims audit, or cost avoidance concepts • Experience developing or supporting audit findings, corrective action plans, executive-ready reporting, analytical summaries, methodology documentation, quality checks, or recurring performance reports • Strong analytical, documentation, quality assurance, and stakeholder coordination skills • Experience using SharePoint, Microsoft Teams, Outlook, Excel, or comparable tools • Ability to research and analyze Medicaid policies, claims, provider oversight, payment integrity, and program integrity requirements • Ability to handle sensitive program, operational, provider, member, client, PII/PHI, and HIPAA-related information in accordance with confidentiality and data-security expectations • Availability during Hawaii Standard Time working hours • Ability to travel approximately 30%–50% of the time, including travel to Hawaiʻi • Preferred experience with Medicaid fraud risk assessments, TPL, PERM, payment integrity, and public-sector health-program analytics • Preferred experience reviewing Medicaid medical, dental, behavioral health, and pharmacy claims • Preferred experience coordinating with client stakeholders, vendor partners, project leadership, and cross-functional workstreams • Relevant certifications such as CPC, CHC, CPMA, CFE, CIA, or equivalent are preferred • Preferred experience with Jira, SQL, Power BI, Tableau, or comparable analytics and dashboarding tools

🏖️ Benefits

• Flexible work location, including fully onsite, hybrid, or remote arrangements • Benefits supporting physical, mental, career, social, and financial well-being • Reasonable accommodation for the application, interview, and job-performance process • Learning, development, and well-being focus • Equal employment opportunity workplace