This position assumes the broad responsibility for the design and implementation of programs to detect, combat and eliminate fraud, waste and abuse in the Medicaid program. In addition, the Nurse Auditor formulates detailed audit plans, conducts, and documents audits of Medicaid providers, in compliance with Government Auditing Standards, identifies specific monetary recoveries/savings, and formulates follow-up recommendations to prevent recurrence of identified problems and enhance the overall efficiency, effectiveness, and economy of the Medicaid program. This position also identifies potential areas of audit activity and develops Medicaid audit capability and surveillance functions and plans, coordinates, monitors, and performs complaint investigations, utilization review, and other activities, as may be required, to establish an audit universe and define a comprehensive, targeted audit program.
The Nurse Auditor formulates, proposes and implements policy initiatives, Administrative Rules and other appropriate program modifications to eliminate or reduce fraud, waste, and abuse, monitors and documents audit follow-up activities to ensure timely completion of both recoupment and necessary remedial actions, defends audit findings, as may be required, as a witness or expert witness in legal and administrative proceedings. Lastly, this position serves as a liaison between the OIG and other agencies involved in the detection and prevention of healthcare fraud and abuse and provide training and technical assistance to OIG staff, other auditors, the Department of Justice, other agencies and providers.
Due to the nature of the position, all applicants who may be appointed will be required to allow DHS to conduct a background check to determine whether the circumstances of any conviction may be related to the job being filled.
This position works from the office in Madison and requires travel, 1-2 times per month on average. This position does not allow the option to telecommute.
Minimally qualified candidates will possess:
Current, unrestricted licensure as a registered nurse. Must be registered in Wisconsin prior to appointment.
Experience working as an RN performing direct care activities in two or more clinical specialties (e.g., working in the same hospital in ICU and rehab would qualify) OR increasing responsibilities in one clinical specialty (e.g., floor nurse to charge nurse in one clinical specialty would qualify).
Experience with electronic health record systems.
Proficiency in Microsoft Office including Excel, Word, Access and/or Outlook
Excellent verbal and written communication skills.
Well qualified candidates will also possess:
Experience developing or participating in the development of policies or procedures in a medical or legal setting.
Experience in program integrity activities such as reviewing medical records for compliance with policies and/or reviewing medical claims for correct coding or unusual billing patterns.
Experience interpreting data in a healthcare setting.
Medical coding or other program integrity certification.
State Of Wisconsin