Virginia Premier Health Plan, Inc.

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Program Integrity Analyst II

Program Integrity Analyst II

Job Locations 
US-VA-Glen Allen
Job ID 
2017-4142

Job Description

Overview

This position is responsible for performing provider audits to identify potential fraud, waste, abuse, or erroneous billing. The Program Integrity Analyst II will identify aberrant trends from claims data and review medical records to determine if billing patterns are justified.  The Program Integrity Analyst II should be a subject matter expert as it relates to the state and federal guidelines for Program Integrity. 

 

Responsibilities

  • Develop reports related to multiple product lines and business units
  • Conducts provider audits based on the annual work plan and referrals to include data analysis, audit reports, recovery of overpayments, and corrective action plans
  • Refers investigations and suspected fraud to appropriate regulatory agencies
  • Perform basic to intermediate SQL queries
  • Develop an expertise in fraud, waste, and abuse reporting systems
  • Assist in the analytical research and presentation of business opportunities
  • Mentors new employees, student workers and interns
  • Identify areas for process improvement within the audit process and present possible solutions
  • Research statutes, laws, and rules that pertain to clinical documentation and practice
  • Effectively communicates with providers and external regulatory agencies regarding audit processes and findings
  • Communicate with providers regarding audit findings
  • Drafts Program Integrity policies and procedures as needed
  • Other duties as assigned

Qualifications

MINIMUM EDUCATION REQUIREMENTS

  • Bachelors Degree in Business Administration, Health Administration, Finance, Statistics, Criminal Justice, or a Science degree in the Healthcare field; or
  • Registered Nurse/Licensed Practical Nurse licensure; or
  • Relevant audit/investigative experience (5-7 years)

SPECIAL KNOWLEDGE AND/OR SKILLS

  •  Proven ability to analyze, visualize, and present data
  • Ability to review medical records for correct documentation
  • Knowledge of common healthcare fraud, waste, and abuse schemes
  • Knowledge of Microsoft software (Word, Excel, Access, and PowerPoint)
  • Ability to communicate effectively, both written and verbal, with technical, clinical and business owners, at the Plan and Corporate Office levels
  • Ability to actively contribute in team based environments

 

WORK BACKGROUND/EXPERIENCE

  • Required: Minimum 2-3 years of experience in healthcare auditing and medical record reviews
  • Preferred: Minimum 2-3 years of experience in Medicaid/Managed Care auditing and investigation
  • Preferred: CPC, CCS, CFE, or AHFI certification.

 PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position.

About Us

Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 

 

We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  

 

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

 

Our mission is to inspire healthy living within the communities we serve!

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