Medicaid Audit Program Coordinator - WV Departments of Health, Health Facilities, and Human Services : Job Details

Nature of Work

This position administers programs within the Office of Program Integrity, with a focus on identifying and recovering overpayments through contracted vendors conducting audits on behalf of the agency.

The role serves as a subject matter expert for team members who review billing records, client treatment documentation, and narrative recordings to assess whether Medicaid service utilization aligns with proper billing practices and program guidelines, and to identify potential audit opportunities.

Key responsibilities include:

• Conducting on-site reviews of Medicaid providers to evaluate:
• Accuracy of submitted claims
• Compliance with documentation requirements
• Adherence to medical necessity criteria
• Conformance with Medicaid policy
• Reviewing new and revised federal and state Medicaid regulations and recommending appropriate audit activities in response to regulatory changes.
• Evaluating Medicaid policies and reimbursement methodologies to suggest improvements in clarity, consistency, or enforceability.
• Communicating effectively, both orally and in writing, with:
• Representatives of the medical provider community
• Administrative and medical professional staff within state agencies
• Private organizations regarding Medicaid policies and audits

Performs other related duties as assigned.

Minimum Qualifications

Training: Bachelor's Degree from a regionally accredited four-year college or university.

Substitution: Additional experience as described below may be substituted for the required training on a year-for-year basis.

Experience: Four years full-time, equivalent part-time paid or volunteer experience in a technical or program area that is related to the area of employment.

Substitution: Post-graduate education in a field related to the technical or program area may be substituted for the required experience on the basis of fifteen semester hours for one year of experience.