Provider Network Auditor

Job Description

Job Description

SCCMHA JOB VACANCY ANNOUNCEMENT

CLASSIFICATION: Provider Network Auditor

PAY RANGE: $62,729.36 - $77,204.58 annually

POSITION SUMMARY:

Under general supervision of the Provider Network Auditing Supervisor, responsible for conducting program audit functions for Saginaw County Community Mental Health Authority (SCCMHA) as part of a compliance and quality performance program to safeguard against fraudulent or erroneous claims of consumer service provision on behalf of SCCMHA. Working with approved regulatory and contractual guidelines and SCCMHA policies, this position will work individually or in a team to initiate, compile, complete, document and analyze audit findings for SCCMHA. Audits both contracted and board operated programs. Verifies event documentation and identifies system deficiencies by provider (i.e. billing code and modifier deficiencies). Reviews provider service delivery records and may conduct contractor compliance reviews. Presents summary information to key SCCMHA management team staff as requested or indicated. Represents SCCMHA to the provider network in monitoring and compliance measurement verbal and written communications. Required to develop in-depth knowledge of service requirements for varied SCCMHA programs. This position will be knowledgeable about and actively support culturally competent recovery based practices; person centered planning as a shared decision making process with the individual, who defines his/her life goals and is assisted in developing a unique path toward those goals; and a trauma informed culture of safety to aid consumer in the recovery process.

ESSENTIAL DUTIES AND RESPONSIBLITIES:

1. Establishes audit samples, basis, schedules and plans with audit team members.

2. May be assigned specific program types for audit tasks based on experience or SCCMHA needs.

3. Contributes to audit program development; recommends modifications based on testing or use.

4. Conducts annual, routine or ad-hoc SCCMHA audits or provider reviews to meet organizational goals.

5. Identifies areas of deficiency based on audit results, and recommends corrective areas for provider network members, including causation analysis and implementation of preventative actions.

6. Presents audit findings to providers, including explanation and justification for negative findings and/or audit score levels.

7. Reviews provider corrective action plans and outcomes for compliance to audit standards and recommends SCCMHA and provider proactive steps for future compliance.

8. Conducts audits or performance reviews based on consistent, objective standards.

9. Verifies that service events occurred and are properly documented to support legitimate SCCMHA authorization of funds such as billing codes and staff credential for billing services.

10. May conduct contract compliance or other provider record audit reviews.

11. Prepares letters of event verification findings and presents data to be easily reported to MDCH for annual reporting.

12. Visits provider programs on-site and reviews all necessary files and documentation for audit purposes.

13. Establishes audit findings based on documentation and factual materials and presentations.

14. Interprets and exercises appropriate cautions in the interpretation of audit findings for department or management staff as well as applicable providers.

15. Alerts Department and SCCMHA management regarding serious, immediate findings.

16. Alerts the Office of Recipient Rights of any issues that might pertain to a violation of the Michigan Mental Health Code.