Provides knowledge of Medicaid regulations to support the Vulnerability Program Management contract. Collaborates with other Medicaid team members (data team, finance team, research analysts, and other SMEs) to identify areas of risk, vulnerabilities, and Medicaid dollars at risk.

• Develop and maintain the audit schedule• Audit staff as outlined in the system auditing policies• Facilitate compliance with the auditing process• Act as a consultant related to system auditing to others in the unit, department, and health plan • Coordinate auditing outcomes with the trainer to identify, develop, and publish corrective actions/educational material related to audit errors• Ensure compliance with contract provisions with various agencies and applicable State and Federal laws• Support department with regulatory filings as needed• Analyze and determine the best course of action for each inquiry/problem• Develop and update plan policies and procedures to ensure compliance with federal and state requirements• Conduct periodic assessments and audits to ensure compliance with contractual and regulatory requirements and timeliness of submission as needed• Validate monthly and quarterly reports using clinical documentation system (TruCare)• Verify provider participation status using Portico and Amysis• Verify provider address and correct as needed.

• Review Medicare Inpatient Rehabilitation Facility (IRF), Inpatient Psychiatric Facility (IPF), Intensive Outpatient Program (IOP), and B of A claims to determine Medicare fraud• Notify Medicare providers of determinations• Compile summary of findings of each case for Benefit Integrity employees• Assist with developing education for co-workers learning new benefit review categories• Participate in onsite audits and investigations• Interview Medicare beneficiaries regarding the services rendered and billed• Collaborate with outside agencies regarding determinations• Follow Center for Medicare and Medicaid Services (CMS) guidelines• Mentor co-workers as requested.

• Review Inpatient Rehabilitation Facility (IRF), Inpatient Psychiatric Facility (IPF), B of A, RAC, bariatric (70035 edit), 2 Midnight, and Recovery Audit Contractor (RAC) Medicare claims to determine medical necessity• Notify beneficiaries and Medicare providers of the determination decisions• Record decision making process on worksheets• Determine medical necessity using InterQual criteria• Maintain records for Quality Assurance• Assist with work instructions to update processes as needed• Provide audits of provider appeals• Follow Center for Medicare and Medicaid Services guidelines.

• Care Coordination for Medicaid members• Developing care plans for providers and members• Follow up phone calls to check on members’ health status and status of care plan goal completion• Updating care plan dashboard with results of member outreach• Prenatal education for pregnant members• Distributing educational materials to members.

• Coordinate on-site visits of Managed Care teams completing performance audits of the Medicaid Managed Care Health Plans (including SCHIP programs) • Quality assurance for SC Medicaid Managed Care health plans• Assist managed care plans with corrective actions plans to address deficiencies reported in audits• Participate in unannounced audits of Medicaid Managed Care Health Plans• Review monthly health plan reports• Coordinate reports (including HEDIS data) for SCDHHS staff• Assist in developing the state Health plan report card• Assist External Quality Review Organization with audits and workshops• Perform as liaison between and health plan member and health plan regarding access to care and quality assurance issues.