SeattleCH 工作分析
💡 智能摘要
原始职位描述
岗位描述
程序完整性审计员（HCPS/DAIO）
71029001
该健康护理计划专员担任审计员角色，帮助识别欺诈、浪费和滥用行为，并追回不当支付。该职位提供灵活的工作方式，您可以自行制定审计方法和重点。您是否天生具有解决问题的亲和力和热情？您是否在寻找工作与生活的平衡、优厚的福利和稳定的工作？这可能就是适合您的职位！
所有HCA员工在工作中将应用公平性视角，这可能包括但不限于对核心业务和流程的所有分析。。
关于部门：
审计、诚信与监督部（DAIO）负责提供监督，帮助确保我们医疗采购和资助活动的诚信。这包括对医疗及其他福利提供者和受益人的审计；识别、预防和调查欺诈、浪费和滥用；资助次级受助人监督；医疗管理组织合同监督；PEBB/SEBB监督；以及对行为健康和康复支出的监督。
关于该职位：
该职位在审计、调查与监督单元担任审计员。该职位进行提供者使用情况的调研和数据分析；审计、审查和调查Apple Health医疗提供者，以识别潜在的欺诈、浪费和滥用行为，并追回相关不当支付，将可信的欺诈和医疗服务质量/执照问题举报给相关机构。通过这些程序完整性工作，该职位支持HCA的使命：“通过创新的健康政策和采购策略，提供高质量的医疗服务。”
该职位可远程办公，但可能需要定期到岗。 可能需要进行少量出差以参加培训、会议或活动。 所有健康护理机构（HCA）职位的默认工作地点（包括远程办公和可远程办公职位）均位于华盛顿州。该职位的汇报地点为华盛顿州奥林匹亚市。到岗工作的频率将根据业务和运营需求而变化。 所有机构员工在入职和离职的第一天必须到奥林匹亚市现场报到，领取和归还州政府发放的设备，无论是否为远程办公或工作地点。
工作职责
您将要做的部分工作：
- 规划并开展对Apple Health提供者索赔的审查和审计，以确定其是否符合相关联邦和州法规；机构规则、政策和收费指南；以及合同或协议。
- 利用数据分析来识别可能代表潜在欺诈、浪费或滥用行为的风险模式和异常值。
- 记录审计结果，识别任何不当支付，并根据规则、政策和收费指南得出结论。
- 准备专业的审计报告，总结审计结果。
- 在非正式争议过程中及正式申诉过程中，代表HCA提供专家证词，解释并捍卫审计结果。
- 在审计过程中提供提供商教育，并参与教育性演讲。
- 提供有关健康政策和程序解释、项目分析以及监测与改进活动方面的技术援助。
- 识别华盛顿州Apple Health提供商指南及其他规则中可以加强的领域，以明确并提高提供商的合规性。
资格要求
必备资格：
符合条件的候选人将满足 以下任一标准： 选项 1：
拥有公共卫生、公共或工商管理、审计或相关领域的硕士学位。
- 具备两年（2年）的健康服务工作经验，包括但不限于直接为客户提供服务、理赔审核或授权以及业务运营，或专业审计经验。
- 选项 2：
拥有公共卫生、公共或工商管理、审计或相关领域的学士学位。
- 具备四年（4年）的健康服务工作经验，包括但不限于直接为客户提供服务、理赔审核或授权以及业务运营，或专业审计经验。
- 选项 3：
具备八年（8年）的健康服务工作经验，包括但不限于直接为客户提供服务、理赔审核或授权以及业务运营，或专业审计经验。
- 选项 4：
在州政府担任健康服务项目顾问一年，职责包括在健康服务、社会服务或医疗补助项目中担任监督或咨询角色，包括对医疗理赔的审核或审查。
- 必备知识、技能与能力：
Required Knowledge, Skills, and Abilities:
- 能够采取行动不断学习和成长。
- 能够采取行动以满足他人的需求。
- 注重细节，具备理解数据细微差别和变量的能力。
- 保持客观的心态，并能展示出运用合理标准得出事实结论的能力。
- 能够展示清晰、有效的口头和书面沟通能力。
- 能够展示从多种资源中获取信息的能力，提炼内容并制作全面、有信息量的报告。
- 熟练使用微软软件，包括Word和Excel。
优先考虑的资格：
- 具备医疗术语和医疗文件解读的工作知识。
- 了解医疗审计的概念和原则。
- 具备开展医疗记录审核的工作经验，并能够解读和应用联邦和州法规、编码和收费要求。
- 展示出在数据挖掘、数据解读和数据分析方面的经验。
- 了解当前及发展的医疗保健服务和收费趋势。
如何申请：
仅考虑在NEOGOV个人资料中反映最低资格要求的候选人。未按照以下申请说明操作可能导致被取消资格。 申请此职位时，您需要完成个人资料，包括三名专业参考人，并将它们作为单独文件附加：
- A 求职信 其中具体说明您如何满足该职位的资格要求
- 当前 简历
为享受 退伍军人优先权，请执行以下操作：
- 请附上您的 DD214（成员 4 长格式副本）、NGB 22 或 USDVA 签署的服役证明信。
- 请遮盖任何个人身份信息（PII）数据，如社会安全号码。请在 careers.wa.gov 上使用您申请中出现的姓名。
补充信息
关于 HCA：
作为该州最大的医疗保健购买者和行为健康主管机构，华盛顿州医疗保健管理局（HCA）在确保华盛顿居民有机会尽可能保持健康方面处于领先地位。
我们工作的三大支柱包括：Apple Health（医疗补助）；公共雇员福利委员会（PEBB）和学校雇员福利委员会（SEBB）计划；以及行为健康与康复。在这些支柱下，HCA 为超过 270 万华盛顿居民购买医疗保健，包括行为健康治疗，并向所有华盛顿居民提供行为健康预防、危机和康复支持。
我们能为您提供：
- 与友善同事一起从事有意义的工作，他们关心我们服务的对象 HCA 的声音
- 一个清晰的机构使命，指导我们的工作，并以个人为中心 HCA 的使命、愿景与价值观
- 健康的工作与生活平衡，包括灵活的工作时间安排和移动办公选项。
- 优秀的整体薪酬和福利套餐 华盛顿州政府福利
- 安全、舒适的办公场所，位于交通便利、附近有餐厅和购物设施的地点。
- 并且还有免费停车位！
说明：
在新员工入职前，将进行包括犯罪记录在内的背景调查。背景调查所得信息并不一定会影响雇佣决定。
HCA 是一家平等机会雇主。我们重视营造一个让所有员工都能感到被尊重、被包容，并能够贡献独特想法的工作环境。HCA 拥有五个员工资源小组（ERGs）。ERGs 是自愿参与、由员工主导的组织，旨在促进一个多样化、包容性的工作环境，与 HCA 的使命相一致。 我们的多样性和包容性努力包括接纳不同的文化、背景和观点，同时促进工作场所的成长与晋升。 研究表明，除非女性、种族和民族少数群体以及残疾人感到自己符合职位描述中的所有资格要求，否则他们不太可能申请工作。年龄超过 40 岁、残疾人以及越战退伍军人，以及所有性取向和性别认同的人士也鼓励申请。如果您对所需的资格有任何疑问，或想了解您的经验如何与这些资格相关，请联系我们： HCAjobs@hca.wa.gov. 需要申请过程中协助的残疾人，或需要此职位公告替代格式的人士，可联系 Angelic Matthews，邮箱地址为 angelic.matthews@hca.wa.gov
华盛顿州卫生保健管理局（HCA）是 E-Verify 雇主。所有在美国有 合法工作权利 的申请人均被鼓励申请。
E-Verify® 是美国国土安全部的注册商标。
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订阅我们的每周简报 以获取 HCA 的最新职位公告列表。
SeattleCH Job Analysis
💡 Smart Summary
Original Job Description
Description
Program Integrity Auditor (HCPS/DAIO)
71029001
This Health Care Program Specialist functions as an auditor and helps ensure that fraud, waste, and abuse is identified and improper payments are recovered. This position offers the flexibility to create your own audit approach and focus. Do you have a natural affinity and passion for problem solving? Are you looking for work life balance, great benefits and stability? This might be the right fit for you!
All HCA employees will apply an equity lens to their work, which may include but is not limited to all analyses of core business and processes.
About the division:
The Division of Audit, Integrity, and Oversight (DAIO) is responsible for providing oversight and helping ensure the integrity of our healthcare purchasing and grant activities. This includes auditing medical and other benefit providers and beneficiaries; the identification, prevention, and investigation of fraud, waste, and abuse; grant subrecipient monitoring; managed care organization contract monitoring; PEBB/SEBB monitoring; and the oversight of behavioral health and recovery spending.
About the position:
This position serves as an auditor in the Audit, Investigation, and Monitoring unit. It conducts research and data analysis of provider utilization profiles; and audits, reviews, and investigates Apple Health healthcare providers to identify potential fraud, waste and abuse and recover related-improper payments, and refers credible allegations of fraud and quality of care/licensing issues to the appropriate authority. Through these program integrity efforts, the position supports the HCA’s mission to “Provide high quality health care through innovative health policies and purchasing strategies.”
This position is eligible to telework, however, may be required to report on-site periodically. Minimal travel may be required to attend training, conferences, or events. The default assigned work location of all Health Care Authority (HCA) positions – both on-site and telework eligible positions – is within the State of Washington. This position reports to Olympia, WA. Frequency of onsite work will vary based on business and operational needs. All agency employees are required to report on-site in Olympia on their first and last days of employment to pick up and return state-issued equipment, regardless of telework status or location.
Duties
Some of what you will do:
- Plan and conduct reviews and audits of Apple Health provider claims to determine compliance with associated federal and state regulations; agency rules, policies and billing guides; and contracts or agreements.
- Use data analytics to identify risk patterns and outliers that could represent potential fraud, waste, or abuse.
- Document the audit results identifying any improper payments with conclusions based on rule, policy and billing instructions.
- Preparing professional audit reports summarizing the results.
- Represent HCA in providing expert testimony to explain and defend audit findings throughout the informal dispute process and the formal appeal process.
- Provide provider education throughout the audit process and participate in educational presentations.
- Providing technical assistance concerning the interpretation of health care policy and procedures, program analysis, and monitoring and improvement activities.
- Identify areas in the Washington Apple Health Provider Guides and other rules that could be strengthened to clarify and improve provider compliance.
Qualifications
Required qualifications:
Qualifying candidates will meet one of the following criteria options:
Option 1:
- Master’s degree with a major study in public health, public or business administration, auditing, or a related field.
- Two (2) years of experience in health services, including but not limited to direct services to clients, claims review or authorization, and business operations, or professional auditing.
Option 2:
- Bachelor's degree with a major study in public health, public or business administration, auditing, or a related field.
- Four (4) years of experience in health services, including but not limited to direct services to clients, claims review or authorization, and business operations, or professional auditing.
Option 3:
- Eight (8) years of experience in health services, including but not limited to direct services to clients, claims review or authorization, and business operations, or professional auditing.
Option 4:
- One year as a Health Care Program Consultant in State Government with duties and responsibilities in a supervisory or consultative capacity in health services, social services or Medicaid programs, including audits or reviews of healthcare claims
Required Knowledge, Skills, and Abilities:
- The ability to take action to learn and grow.
- The ability to take action to meet the needs of others.
- Detail-oriented with the ability to understand the nuances and variables of data.
- An objective mindset and a demonstrated ability to apply sound criteria in reaching fact-based conclusions.
- Demonstration of clear, effective oral and written communication skills.
- Demonstration of the ability to gather information from a variety of resources. Condense content and produce comprehensive, informative reports.
- Proficient in the use of Microsoft software, including Word and Excel.
Preferred qualifications:
- Working knowledge of medical terminology and interpretation of health care documentation.
- Knowledge of healthcare auditing concepts and principles.
- Working experience conducting medical record reviews and ability to interpret and apply Federal and State regulations, coding and billing requirements.
- Demonstrated experience in data mining, data interpretation, and data analysis.
- Knowledge of current and developing trends in medical healthcare delivery and billing.
How to apply:
Only candidates who reflect the minimum qualifications on their NEOGOV profile will be considered. Failure to follow the application instructions below may lead to disqualification. To apply for this position, you will need to complete your profile which includes three professional references and attach them in separate files:
- A cover letter that specifically addresses how you meet the qualifications for this position
- Current resume
To take advantage of veteran preference, please do the following:
- Attach a copy of your DD214 (Member 4 long-form copy), NGB 22, or USDVA signed verification of service letter.
- Please black out any PII (personally identifiable information) data such as social security numbers. Include your name as it appears on your application in careers.wa.gov.
Supplemental Information
About HCA:
Functioning as both the state's largest health care purchaser and its behavioral health authority, the Washington State Health Care Authority (HCA) is a leader in ensuring Washington residents have the opportunity to be as healthy as possible.
There are three pillars of our work: Apple Health (Medicaid); the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs; and behavioral health and recovery. Under these pillars, HCA purchases health care, including behavioral health treatment for more than 2.7 million Washington residents and provides behavioral health prevention, crisis, and recovery supports to all Washington residents.
What we have to offer:
- Meaningful work with friendly co-workers who care about those we serve Voices of HCA
- A clear agency mission that drives our work and is person-centered HCA's Mission, Vision & Values
- A healthy work/life balance, including alternative/flexible schedules and mobile work options.
- A great total compensation and benefit package WA State Government Benefits
- A safe, pleasant workplace in a convenient location with restaurants, and shopping nearby.
- And free parking!
Notes:
Prior to a new hire, a background check including criminal record history will be conducted. Information from the background check will not necessarily preclude employment.
HCA is an equal opportunity employer. We value the importance of creating an environment in which all employees can feel respected, included, and empowered to bring unique ideas to the agency. HCA has five employee resource groups (ERGs). ERGs are voluntary, employee-led groups whose aim is to foster a diverse, inclusive workplace aligned with HCA’s mission. Our diversity and inclusion efforts include embracing different cultures, backgrounds and viewpoints while fostering growth and advancement in the workplace. Studies have shown women, racial and ethnic minorities, and persons of disability are less likely to apply for jobs unless they feel they meet every qualification as described in a job description. Persons over 40 years of age, disabled and Vietnam era veterans, as well as people of all sexual orientations and gender identities are also encouraged to apply. If you have any questions about the required qualifications or how your experience relates to them, please contact us at HCAjobs@hca.wa.gov. Persons with disabilities needing assistance in the application process, or those needing this job announcement in an alternative format may contact Angelic Matthews at angelic.matthews@hca.wa.gov
The Washington State Health Care Authority (HCA) is an E-Verify employer. All applicants with a legal right to work in the United States are encouraged to apply.
E-Verify® is a registered trademark of the U.S. Department of Homeland Security.
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