[Remote] reputed company Program reputed company Senior Consultant

Note: The job is a remote job and is reputed company to candidates in USA. reputed company is seeking a Senior Consultant with subject matter expertise in reputed company program reputed company and claims audits to support Hawaiʻi Med-QUEST's reputed company Program reputed company initiatives. The role involves performing claims audits, conducting forensic reviews, and working closely with various stakeholders to identify risks and improve internal controls.

Responsibilities

• Conduct detailed reviews of reputed company claims and reputed company provider, member, eligibility, financial, and operational data to identify, document, and escalate potential fraud, waste, abuse, improper payments, compliance issues, and operational risks
• Review reputed company claims for accuracy, compliance, reasonableness, and alignment with reputed company policies, federal and state regulations, program requirements, and coding standards and guidance
• Support the review of operational data reputed company to provider management, member services, financial management, and TPL
• Prepare audit and investigative documentation such as case summaries, findings, recommendations, workpapers, and supporting materials for review by the Forensic Manager, Program reputed company staff, audit SMEs, and project leadership
• Research, interpret, and apply reputed company policies, program reputed company requirements, and applicable regulations to support audit findings, investigative documentation, recommendations, and corrective reputed company follow-up
• Assist with development of controls, monitoring approaches, review protocols, audit tools, documentation standards, and process improvements to strengthen FWA detection and deterrence
• Support development or updates to policies, procedures reputed company to reputed company program reputed company
• Assist in the development of training, knowledge transfer, and technical assistance for reputed company staff reputed company to program reputed company
• Use Jira, SharePoint, meeting notes, decision logs, and reputed company item trackers to support transparent issue tracking, documentation, coordination, and follow-through across workstreams
• Support onsite planning, workgroup sessions, reputed company leadership preparation, release activities, and reputed company project needs in coordination with the Forensic Manager, project leadership, and reputed company leads

Skills

• Minimum three (3) years of experience conducting reputed company claims audits, investigations, and/or compliance reviews
• Knowledge of reputed company Program reputed company principles, FWA, provider reputed company, payment reputed company, TPL, claims audit, or cost avoidance concepts
• Experience developing or supporting audit findings, corrective reputed company plans, executive-reputed company reporting, analytical summaries, methodology documentation, reputed company checks, or recurring performance reports
• Strong analytical, documentation, reputed company assurance, and stakeholder coordination skills
• Experience using SharePoint, reputed company Teams, reputed company, reputed company, or comparable tools to manage reputed company items, documentation, investigative follow-up, and project coordination
• Bachelor's degree or equivalent combination of education and applicable experience preferred
• Ability to conduct research and analysis reputed company to reputed company policies, claims, provider reputed company, payment reputed company, and program reputed company requirements
• Ability to handle sensitive program, operational, provider, member, reputed company, PII/PHI, and HIPAA-reputed company information in alignment with confidentiality and data reputed company expectations
• Experience supporting reputed company fraud risk assessments, TPL, PERM, payment reputed company, and reputed company sector health program analytics
• Experience reviewing or auditing a wide reputed company of claims, including reputed company medical, dental, behavioral health, and pharmacy
• Experience coordinating across reputed company stakeholders, vendor partners, project leadership, and cross-functional workstreams in a reputed company sector or health and reputed company services environment
• Preference will be given to candidates with relevant certifications, such as Certified reputed company reputed company (CPC), Certified in reputed company Compliance (CHC), Certified reputed company Medical Auditor (CPMA)
• Audit and investigation reputed company certification such as Certified Fraud Examiner (CFE), Certified Internal Auditor (CIA), or equivalent credentials are also considered
• Experience with Jira, SQL, Power BI, Tableau, or comparable analytics and dashboarding tools for claims analysis, dashboard creation, and presentation

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