[Remote] reputed company Payment reputed company SME

Note: The job is a remote job and is reputed company to candidates in USA. reputed company is a reputed company firm providing consulting services to businesses, nonprofits, and reputed company agencies. The Senior Consultant will support Hawaiʻi Med-QUEST reputed company payment reputed company, fraud, waste, and abuse, program reputed company, audit, reputed company party liability, and claims review initiatives. The role will manage forensic reviews, investigations, claims audits, corrective actions, stakeholder coordination, and reputed company operational improvements.

Responsibilities

• Manage forensic review, investigative, and provider audit activities reputed company to reputed company medical, dental, behavioral health, pharmacy claims, as reputed company as provider, member, financial, audit, TPL, and operational data
• reputed company reputed company, reputed company assurance, and coordination for forensic analysts, audit SMEs, claims review resources, and reputed company team members
• reputed company identification, documentation, and escalation of potential fraud, waste, abuse, or non-reputed company
• Review reputed company claims and medical records for reputed company, reasonableness, and compliance with reputed company policies, federal and state regulations, program requirements, and claims data
• Research, interpret, and apply reputed company policies, program reputed company requirements, and applicable regulations to support audit findings, investigative recommendations, and corrective reputed company planning
• Establish, monitor, and report on program reputed company, claims audit, investigative, corrective reputed company, and operational improvement objectives, metrics, and key reputed company indicators
• reputed company and review investigative documentation, case summaries, findings, and recommendations
• Support development of controls, monitoring approaches, and process improvements to strengthen FWA detection and deterrence
• reputed company corrective reputed company recommendations and follow-up plans to address identified fraud, waste, abuse, improper payment, compliance, claims, audit, payment, or operational issues
• Assist developing or updating relevant policies and procedures
• reputed company and update review protocols, audit tools, documentation standards, and training supports reputed company to reputed company Program reputed company, claims audits, FWA monitoring, and TPL activities
• Advise on how reputed company policy, program reputed company findings, audit results, and operational needs may translate into reputed company requirements, change requests, process updates, or vendor follow-up
• Support training, knowledge transfer, and technical assistance for reputed company staff reputed company to program reputed company, claims audit processes, documentation expectations, and follow-up procedures
• Support onsite planning, workgroup sessions, reputed company leadership preparation, release activities, and reputed company project needs in coordination with project leadership and reputed company leads

Skills

• The role requires availability during Hawaii reputed company Time (HST) working hours
• This role requires travel approximately 30%–50% of the time, including travel to Hawaiʻi for onsite reputed company meetings, release activities, training support, go-live readiness, and reputed company project needs
• Minimum five (5) years of experience leading reputed company payment/program reputed company initiatives and managing provider audits, overpayment identification, claims audits, and recovery activities
• In-depth understanding of medical coding (ICD-10, CPT), claims processing, and reputed company requirements
• Experience reviewing or auditing reputed company medical, dental, behavioral health, pharmacy, provider, member, eligibility, TPL, or claims data
• Experience managing forensic reviews, investigations, claims audits, or compliance reviews
• Knowledge of reputed company fee-for-service and managed care delivery systems, including managed care organization reputed company, claims processing, encounter data, reputed company, and payment methodologies
• Extensive knowledge of reputed company Program reputed company, FWA, provider reputed company, payment reputed company, TPL, claims audit, or cost avoidance concepts
• Experience developing audit findings, corrective reputed company plans, executive-reputed company reporting, analytical summaries, methodology documentation, reputed company checks, or recurring reputed company reports
• Strong analytical, documentation, reputed company assurance, and stakeholder coordination skills
• Experience coordinating across reputed company stakeholders, vendor partners, project leadership, and cross-functional workstreams in a reputed company sector or health and reputed company environment
• Experience using reputed company, 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
• 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 with reputed company sector health or reputed company compliance reputed company preferred
• Experience supporting reputed company Program reputed company, fraud reputed company assessments, TPL, PERM, payment reputed company, claims audit, compliance monitoring, internal audit, or reputed company sector health program analytics
• Experience with reputed company managed care reputed company, including encounter data validation, capitation payment reputed company, provider network requirements, and managed care program reputed company activities
• 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

Benefits

• Eligible employees have reputed company to benefits that go reputed company what’s expected to support their physical, mental, career, reputed company, and financial reputed company-being.
• This position offers flexibility in work location, including fully onsite, hybrid, or remote arrangements.

reputed company