SIU Compliance Auditor
Job DescriptionThis position is responsible for conducting compliance audits, risk assessments, investigations,
education and training assignments relating to billing, coding, reimbursement and documentations.
At least sixty percent of this position's time involves working in the field with vendors, subcontractors
and providers. This position is also 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 Magellan
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
TitleSIU Compliance Auditor
Job FamilyLegal Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date1/24/2020
Date Requisition Created1/24/2020
EducationBachelors (Required), Masters
License and Certifications - Required
License and Certifications - Preferred
Other Job Requirements
- Experience working for a Managed Care Company or other health related organization.
- Knowledge of group health or managed care claims payment processes.
- Health Care audit-related experience
- 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.
- Healthcare experience.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.
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