Audit & Investigations Unit Manager
The ideal candidate for this position will have a passion and experience with auditing, preferably in healthcare. If you have experience with risk mitigation, data analysis, and have leadership experience, this opportunity may be for you!
Position Objective:
The Audit and Investigation (A&I) Unit Manager reports to the Section Manager and is delegated full program management responsibility to design, develop and maintain a comprehensive statewide audit program for Washington Apple Health (WAH). These activities fulfill the Section's mission to provide reasonable and consistent oversight of WAH programs and contracts to effectively encourage efficiency, compliance, accountability, awareness and responsibility to protect public funds.
Some of what you will do:
Directs and coordinates the activities of 8 professional staff in the audit, review and analysis of WAH programs.
Builds integrity and credibility in the A&I Unit's work processes;
Assures appropriate and optimum use of the unit's resources and enhances the effectiveness of employees through timely appraisal and professional development opportunities;
Maintains the highest standards of personal, professional and ethical conduct and supports the State's goals of a diverse workforce.
Develops, engages, approves and monitors audit work plans, protocols and procedures used by the unit and section.
Develops tools and provides oversight in the detection, evaluation and prevention of potential fraud, waste and abuse in the healthcare provider setting.
Develops cost effective and efficient auditing methods and strategies.
Provides supervisory assistance in conducting desk or onsite provider and Managed Care Organization (MCO) audits, medical service verifications, and provider site visits to validate business is operational.
Collaborates with and supports tribal government to government relationships.
Be dependable, accountable and responsible with honest work ethic and attention to detail and commitment to excellence.
Actively participates as a leader within PI's Case Management Team and offers advice and direction of new leads or tips and case assignment or referral.
Participates in the design, development and maintenance of the Section's Fraud and Abuse Detection and Case Tracking System and any future versions of such.
Oversees cases determined to be credible allegations of fraud, recommends payment suspension or good cause not to suspend payment, and coordinates referral to the Attorney General's Medicaid Fraud Control Division (MFCD) for further investigation and prosecution.
Refers cases identified as having potential quality of care or licensing issues to the agency's Quality Management Team or Department of Health (DOH).
Supports staff by coaching and establishing audit protocols, policies and procedures.
Uses creative and innovative approaches to achieve results and resolve problems.
Responds timely and accurately to written and/or oral questions regarding audit findings and/or the audit process.
Participates in provider dispute resolution process and administrative hearing process, including providing evidence and/or testimony in support of audit findings.
Provides recommendations to executive and program management to strengthen program policies and procedures.
Assists with operational assignments to support the Section and Section Manager.
Completes managerial reports on time to ensure transparency and accountability of the unit's productivity, performance measures and work products.
Works towards the vision, focus and goals of the Section.
This position will use critical thinking and problem solving to address problems and in the absence of guidance from management, exercise prudent independent judgment when making decisions.
The A&I Unit Manager controls and/or influences:
Resources and policies that directly affect the work performed within the unit and section.
Audit findings identified by the Auditor/Analysts not only lead to the recovery of improper payments but also may result in recommendations for policy changes to enhance program integrity within the agency, changes to the adjudication edits and audits within the ProviderOne payment system, and used to educate agency-contracted healthcare providers and entities.
Managing audits and compliance reviews of agency-contracted healthcare provider and managed care entity paid services. These efforts enhance program integrity and identify improper payments to contracted providers. The end result of these reviews is millions of dollars in recovery and possible referrals for potential fraud, or for potential licensing infractions.
Serving as a subject matter expert and provide feedback and recommendations to executive management and program managers for policy changes based on audit findings.
Developing and maintaining internal controls to safeguard the Section's processes are well documented and consistently applied.
Here is what we are looking for (Required Qualifications):
A Master's degree and two years' working experience in human services, public administration, healthcare compliance or audit related field and demonstrated strong leadership skills.
OR
A Bachelor's degree and four years' working experience in the human services, public administration, healthcare compliance or audit related field and demonstrated strong leadership skills.
OR
A Medical Assistance Program Specialist 2 or higher position with additional qualifying experience listed below, may substitute year for year for required education.
• Demonstrated strong leadership skills.
• Knowledge of the principles of management and supervision with ability to prioritize and manage multiple assignments, plan, organize and direct the work of others.
• Knowledge of and ability to plan, organize and direct audits, reviews and investigations of managed care entities and healthcare service providers.
• Knowledge of state and federal law, regulations, rules, policies and procedures relating to Medicaid Program Integrity.
• Knowledge of healthcare fraud, waste and abuse detection methodologies.
• Knowledge of HCA's organization, mission and values, Washington Apple Health programs and managed care entity contracts, HCA's managed care premium calculation and cost reimbursement methodologies and associated rules and regulations.
• Knowledge of auditing principles, standards and sampling methodologies.
• Knowledge of tribal government to government accords.
• Ability to handle complex and comprehensive managed care entity or healthcare service provider compliance and audit issues.
• Ability to effectively utilize interdisciplinary teams to conduct managed care oversight, audits, reviews, and investigations.
• Knowledge of auditing principles, standards and sampling methodologies.
• Knowledge of tribal government to government accords.
• Ability to work effectively in a sometimes adversarial environment, effectively communicate (both in writing and verbally); problem solve; negotiate; manage conflict; manage projects; interview; research; design and implement short and long range plans; analyze; monitor, evaluate and report skills of audit staff; coordinate and collaborate with program management staff.
Desirable/Preferred Qualifications:
Knowledge of Health Insurance Portability and Accountability Act and Personal Health Information privacy rules, regulations, and policies.
Knowledge of the ProviderOne payment system.
Knowledge of data analysis and risk mitigation strategies.
Familiarity with and an understanding of audit standards established by the U. S. Government Accountability Office (GAO) in the publication Government Auditing Standards (GAS).