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Medicaid Fraud & Abuse Analyst

Medicaid Utilization Review Analyst

Health and Welfare

Open for Recruitment: January 8, 2018 - January 22, 2018
Announcement # 09055035669
Salary Range: $21.00 - $24.00 per hour -Plus Competitive Benefits!

Location(s): Coeur d'Alene

The Idaho Department of Health and Welfare, Bureau of Audits and Investigations is searching for a self-motivated individual to investigate and ensure Medicaid provider compliance with Medicaid rules, regulations and policies. The current opening is in the Coeur d'Alene office.

This position is instrumental in protecting the integrity of the Medicaid program. The individual will conduct preliminary investigations, audit Medicaid billings, and represent the Department as an excellent communicator with providers, in presentations, in hearings, with agencies, and with community businesses. A positive and professional image, excellent research and analytical skills, and decisiveness with the ability to communicate well are critical for this position. 

Some travel is required; trips can last from one day to a week. 

The successful candidate will be required to pass a background investigation and an expanded reference check.

If you have previously applied for Medicaid Utilization Review Analyst and wish to be considered for the current vacancy, you must reapply under this announcement. Previous scores will not be used.

Responsibilities:

  • Reviews and analyzes Medicaid Management Information System (MMIS) reports to identify utilization patterns and individual providers or clients who may be abusing the program;
  • Develops cases by interviewing providers and clients, conducts on-site reviews, and documents evidence;
  • Meets with providers to discuss findings;
  • Recommends and participates in development and implementation of policies and procedures for monitoring program utilization;
  • Confers with professional medical consultants concerning appropriateness and quality of medical goods and services provided to clients;
  • Makes and assists with presentations to internal units, provider groups and Medicaid staff on Utilization Review policy and procedures.

Minimum Qualifications:

Good knowledge of:

  • Medical terminology;
  • Medical diagnostic and procedural terms;
  • Data processing systems as used in program monitoring and management information processes;
  • Common medical payment procedural codes used in Current Procedural Terminology Fourth Edition (CPT-4), and other nationally recognized coding references.
Experience:
  • Conducting interviews to obtain facts for cases;
  • Recognizing patterns of medical assistance billing that suggest fraud, abuse, over-utilization, child abuse, and claims processing problems;
  • Compiling, analyzing, and interpreting statistical data, and developing recommendations;
  • Providing verbal and written communication of findings to both internal and external entities.

Additional Qualifications: Are not required; however, having the minimum qualifications and the experience and/or education listed below will increase your score.

  1. Some knowledge of in-depth interviewing techniques and procedures. Typically gained through completion of college coursework or workshop/seminar that discussed interviewing techniques and procedures in detail and was the focus of the coursework or workshop/seminar.  
  2. Some knowledge of court proceedings, testimony and administrative appeals. Typically gained through involvement in the above items in a work capacity.
  3. Experience working with Medicaid Programs and demonstrated knowledge of Medicaid regulations and administrative requirements. Typically gained by at least one year of related work experience. 

Exam:

There is an exam for this position to determine an applicant's eligibility. Click the "Preview Exam" button below to review the exam. You must receive a score of 63 to pass this exam. If at any time during the screening/testing process your response or resume do not support the answers you provided, your name will be removed from the register.

How to Apply:

Click on the Apply Online button to the left and follow the instructions provided to complete the Application Checklist and Exam for this position. When updating your online application information, please select Health and Welfare under "Agencies," full-time under "Job Type/Shift" and Coeur d'Alene under "Cities."

 

Preview Exam

Hiring is done without regard to race, color, religion, national origin, sex, age or disability. In addition, preference may be given to veterans who qualify under state and federal laws and regulations. If you need special accommodations to satisfy testing requirements, please contact the Division of Human Resources.