• Responsible for leading coding teams, coder training, work queue management, performing prebill and second-level coding reviews utilizing auditing tools and applicable software. • Uses knowledge of coding and compliance guidelines to identify potential documentation, coding and reimbursement issues and report these to coding leadership. • Employs critical thinking skills to alert coding leadership to any trends identified in their reviews and to make suggestions for continual process improvement. • Maintains knowledge of CPT and HCC documentation requirements to ensure correct code assignment. • Performs outpatient coding by assigning ICD-CM, CPT codes and appropriate modifiers. • Reviews and responds to outpatient level denials as needed. • Conducts review of outpatient records to include, GI, outpatient surgery, emergency department records, observation, diagnostic, Interventional Radiology and other identified records to validate the code assignment according to official coding guidelines as supported by the clinical documentation in the record. • Monitors and maintains work queues daily to identify, prioritize and assign accounts that need to be coded based on department-specific guidelines and within designated timelines coordinating with leadership. • Mentors and trains coders on application of correct ICD-CD and CPT guidelines. • Assists with and develops educational programs for coding staff, clinical documentation staff and medical staff to including yearly coding/CPT updates. • Codes outpatient records periodically based on review of clinical documentation. • Identifies physician query opportunities following established guidelines when existing documentation is unclear or ambiguous following American Health Information (AHIMA) guidelines and established policy. • Identifies and assists management with the resolution of coding issues, process improvement and system testing for Health Information Management (HIM) applications. • Participates in on site, remote and/or external training workshops and training. • Maintains working knowledge of Centers for Medicare & Medicaid Services (CMS) regulations and applicable carrier local medical review policies. • Collaborates with Coding leadership to develop and maintain coding curriculum and training handbook. • Interacts and assists with other departments to resolve coding issues. • Performs other duties as assigned.

About Us Integrity Management Services, Inc. (IntegrityM) is an award-winning, women-owned small business specializing in assisting government and commercial clients in compliance and program integrity efforts, including the prevention and detection of fraud, waste and abuse in government programs. Results are achieved through data analytics, technology solutions, audit, investigation, and medical review. At IntegrityM, we offer a culture of opportunity, recognition, collaboration, and supporting our community. We thrive off of these fundamental elements that make IntegrityM a great place to work. Our small, flexible workplace offers an exceptional quality of life and promotes corporate-driven sustainability. We deliver creative solutions that exceed goals and foster a dynamic, idea-driven environment that nurtures our employees’ professional development. Large company perks…Small company feel! www.integritym.com In this role, the Medicaid Auditor III will be responsible for performing and reporting on Medicaid Managed Care Plans and providers to identify potential fraud, waste, and abuse; issue findings and recommendations; and identify improper payments. Audit assignments can be programmatic or financial and may range from desk reviews and/or onsite review activities as determined by federal and state regulations. Specific review types may include case management, program payment appropriateness, program and policy compliance, billing, coding and medical record documentation reviews, as well as research and analysis of industry trends. The Medicaid Auditor III will perform audits as assigned which consist of but are not limited to performing licensing and exclusion reviews on providers and work with the medical staff to ensure services are reimbursed meet regulatory requirements. The Medicaid Auditor III will work independently as well as collaboratively with other audit staff.    Job Responsibilities:   - Applies in-depth knowledge of federal and state regulations and healthcare industry standards.    - Comprehends and follows auditing plans and methodologies specific to contract requirements.     - Prioritization and assignment of workload, ensuring adherence to task order policies and procedures.    - Examines and calculates data from financial documents and statements such as provider cost reports as a method of audit.     - Utilize data mining and trend analysis tools to detect anomalies in Medicaid billing and payment patterns.    - Attend on-site audits to retrieve medical records and conduct provider entrance/exit conference.     - Prepare and submit medical record request letters to providers associated with requests for medical record requests or suspension overpayment determinations.    - Interpret and apply pertinent laws, regulations, policies, and procedures relevant to the specific audit findings and provider type being audited.    - Ensure Generally Accepted Government Auditing Standards (GAGAS) standards are applied to each applicable audit to identify fraud, waste or abuse.    - Preparing factual and objective written reports in conformance with professional auditing and evaluation standards and present findings to leadership, external agencies, and government partners.    - Calculates improper payments, and issues findings, recommendations, and corrective actions in accordance with applicable regulations, policies and procedures.     - Prepare and send suspension overpayment determinations to providers when applicable.     - Communicates with federal/state agencies and providers regarding issues such as general regulatory compliance, audit findings, and the recovery process.    - Attends briefings and presentations as assigned.    - Maintains fraud case development quality standards so that proper case development is ensured, and quality cases are fully prepared.     - Maintains proper and timely updates in appropriate tools and applications for their investigations. Case development databases and documents.    - Develops and documents reports of investigative findings, compiles case file documentation, calculates improper payments, and issues findings, recommendations, and corrective actions in accordance with applicable regulations, policies and procedures.     - Program research relating to federal program applications, eligibility, payments, and other program requirements.     - Conducts on-site visits and/or interviews as required for investigation.     - Identify weaknesses in current audit processes and recommend enhancements for improved efficiency and effectiveness.    - Performs ad hoc tasks/duties as assigned.     - Ensures compliance with all applicable privacy and security training requirements (both IntegrityM and external/client-based), whether on an annual or ad/hoc basis. Please note: certain position levels (leads, managers, directors or higher) may require additional “role-based” training to ensure compliance with applicable privacy and security requirements.    - Exercises appropriate discretion and independent judgment relating to company policies and practices in an effective, consistent and professional manner.    - Adheres to applicable policies ensuring commitment to quality, compliance and security to protect the confidentiality, integrity, and availability of sensitive data and information.    - Adheres to all IntegrityM and/or client privacy and security protocols governing sensitive and/or business confidential information.

• Carry out the vision and mission of Internal Audit to enhance and protect organizational value • Support risk-based operational, financial and compliance audits and consulting reviews under the guidance of senior team members • Perform audit procedures including planning, fieldwork, documentation, and follow-up activities related to assessing design and operating effectiveness of internal controls over financial reporting • Evaluate compliance with established policies, procedures, laws and regulations • Identify audit issues and root causes, and contribute to recommendations for improved internal controls and business processes • Prepare clear and concise audit observations and workpapers for review by senior audit staff • Support the development and implementation of corrective action plans • Participate in walkthroughs with process owners and management to understand control environments

• Utilize risk adjustment coding/HCC and HEDIS expertise to perform quality reviews on internal/subcontracted HCC coders/OP CDI. • Use audit tool to analyze quality results and track overall quality. • Provide necessary feedback and research to HCC Coder/ OP CDI in response to coding and documentation questions. • Ability to assess queries for compliance and appropriate composition based on the AHIMA Query Practice Brief. • Prepare and deliver training on HCC documentation requirements, customized to the client audience (e.g., providers, HCC coders). • Assess HCC coders/OP CDI chart reviews for missed documentation or query opportunities impacting RAF scores/HEDIS measures. • Review charts to assure clinical documentation supports MEAT requirements and identify trends in documentation gaps. • Provide education to HCC Coders/OP CDI as needed based on audit findings. • Identify trends and perform training to improve HCC capture, HEDIS measure review, and quality. • Work with Manager to identify performance needs of Coders/OP CDI and create training to increase performance levels.