Senior Compliance Analyst - Glen Allen, VA

Richmond VA 23219

Job Description

**This position is located in our Glen Allen, VA office**

The ideal candidate will have three-to-five years of healthcare compliance audit experience.

Responsible for conducting compliance audits, risk assessments, investigations, education and training assignments relating to billing, coding, reimbursement and documentations. At least sixty percent of the time involves working in the field with vendors, subcontractors and providers. Responsible for conducting claims and compliance audits for the purpose of detecting and/or recovering inappropriate benefit payments due to billing inaccuracies and/or abusive and fraudulent practices, as well as complying with state and federal regulatory compliance and fraud reporting requirements.

Essential Functions

- Conduct reviews of behavioral health consumers? medical record to assess whether covered behavioral health services delivered to the consumer and billed to Medicaid are accurate and appropriate. Prepare detailed audit findings reports. Track and trend compliance statistics and use to implement strategies to improve provider compliance. Implement corrective action as necessary to ensure the highest levels of provider compliance. Conduct re-audits of providers? medical records to verify corrective actions were fully implemented and effective.
- Collaborate and work in coordination with other subject matter experts in Special Investigations Unit (SIU), cost containment, legal, claims, network, compliance and external county and federal and state regulatory authorities such as the Bureau of Program Integrity, Department of Public Welfare, Office of the Attorney General and others to identify, investigate and report overpayment, duplicative payment, false claims, abuse, and fraud situations and, as appropriate, assist in the process of recovery of overpayments.
- Review and monitor provider compliance with Medicaid Licensing and billing requirements in all levels of Medical Assistance funded care. Conduct provider and member interviews as a part of the overall review process.
- Ensure providers have a compliance plan and policies and procedures that detail provider expectations. Review, monitor and report on providers? effective implementation of the plan.
- Further develop comprehensive audit and monitoring tools, provider compliance plan expectations, provider training materials and reporting templates etc. Provide technical assistance as needed.
- Present findings reports at designated meetings (i.e. internal, customer, provider, etc.)
- Ensure compliance regarding HIPAA regulations and forward mandatory reports to designated recipients. Other compliance related duties as instructed.

General Job Information


Senior Compliance Analyst - Glen Allen, VA



Job Family

Legal Group


United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date


Date Requisition Created


Minimum Qualifications


Bachelors (Required), Masters

License and Certifications - Required

License and Certifications - Preferred

Other Job Requirements


Knowledge of Medicaid licensing and billing requirements, DSM-IV; ability to collaborate with many functional areas of a national organization. Large and, at times, complex database management skills coupled with strong working knowledge of Excel. Knowledge of HIPAA.Experience working for a Managed Care Company or other health related organization. Knowledge of group health or managed care claims payment processes.Health Care, preferably audit related experience

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled

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