SIU Compliance Auditor

United States

Job Description

This 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


SIU Compliance Auditor



Job Family

Legal Group


United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date


Date Requisition Created


Work Experience



Bachelors (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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