Payment Integrity Subject Matter Expert (SME)

Overview BerryDunn is seeking a Payment Integrity Subject Matter Expert (SME) to support Hawaiʻi Med-QUEST's Fraud, Waste, and Abuse (FWA), Program Integrity, audit, Third Party Liability (TPL), payment integrity, claims review, and improper payment prevention initiatives. This position will provide subject matter expertise in Medicaid program integrity, claims audits, risk assessment, external audit coordination, interpretation and application of Medicaid policy and applicable federal and state requirements, and development of data-driven methodologies to identify improper payments, billing anomalies, fraud risks, compliance issues, cost avoidance opportunities, and recovery opportunities across Medicaid medical, dental, behavioral health, pharmacy, provider, member, financial, and operational data.  In this role, the Payment Integrity SME will work closely with Program Integrity staff, forensic specialists, audit and TPL subject matter experts, data analysts, compliance SMEs, integrated IT, operations, and policy workstream members, vendor partners, and project leadership to translate Medicaid policy, program needs, claims analytics, and audit findings into practical monitoring approaches, review priorities, system requirements, change requests, operational recommendations, corrective action supports, and process improvement considerations. The SME will support dashboards, reporting, documentation quality, issue escalation, knowledge transfer, quality assurance, and ongoing improvement of payment integrity activities.  Travel expectations: This role may require travel up to 25% of the year. You Will Develop, refine, and apply analytics approaches to identify improper payments, billing anomalies, outliers, fraud risk indicators, cost avoidance opportunities, recovery opportunities, and program integrity risks across Medicaid medical, dental, behavioral health, pharmacy, provider, member, financial, audit, TPL, and operational data.  Support design, validation, and use of dashboards, monitoring tools, reports, review protocols, and decision-support products for payment integrity, claims audit, FWA, TPL, corrective action, and operational improvement activities.  Analyze claims, provider, member, utilization, financial, and operational data to identify high-risk services, billing patterns, provider types, program areas, documentation gaps, policy issues, and potential overpayment or cost avoidance opportunities.  Collaborate with Program Integrity, forensic, compliance, audit, TPL, Medicaid data analysts, integrated IT, policy, operations, and vendor partners to prioritize review areas, validate findings, interpret results, and coordinate follow-up activities.  Develop data-driven methodologies, business rules, review criteria, documentation standards, and repeatable monitoring approaches that support consistent payment integrity reviews, investigative referrals, audit support, and reporting.  Support development of recommendations for cost avoidance, recovery, improved program controls, policy clarification, process improvement, system edits, vendor follow-up, and corrective action planning based on claims analytics and program integrity findings.  Establish, monitor, and report on Medicaid program integrity objectives, payment integrity priorities, claims audit activities, corrective action progress, operational improvement objectives, and key performance indicators.  Research, interpret, and apply Medicaid payment policy, program integrity requirements, audit findings, federal and state requirements, managed care contract expectations, provider billing guidance, and operational procedures to support defensible review conclusions and recommendations.  Review and audit Medicaid claims for accuracy, legality, reasonableness, medical and program policy alignment, billing code validity, service limit compliance, and consistency with claims data and applicable Medicaid requirements.  Document and report claims audit findings, payment integrity observations, risk indicators, analytical results, and recommended actions clearly and consistently for management, client stakeholders, vendors, and project leadership.  Develop or update payment integrity procedures, review protocols, audit tools, monitoring guides, dashboard requirements, report templates, training materials, and knowledge transfer supports for client staff and project team members.  Advise on how payment integrity findings, Medicaid policy interpretations, audit results, and operational needs may translate into system requirements, change requests, process updates, claims edits, documentation improvements, or vendor follow-up.  Conduct Medicaid systems research and analysis, including member benefit groups, billing codes, system configuration, service limits, system requirements, electronic billing standards, adjudication logic, and other configuration or policy elements that affect payment integrity outcomes.  Support training, technical assistance, workgroup facilitation, release readiness, go-live support, and knowledge transfer related to payment integrity analytics, review processes, dashboard use, documentation expectations, and follow-up procedures.  Provide quality assurance reviews of work completed by peers, including claims audit documentation, analytical findings, review protocols, reports, corrective action supports, and client-facing deliverables.  Use Jira, SharePoint, meeting notes, decision logs, action item trackers, dashboards, and reporting tools to support transparent issue tracking, documentation, coordination, and follow-through across our workstreams.  Support onsite planning, payment integrity workgroup sessions, release activities, operational readiness, and related project needs in coordination with project leadership and workstream leads.  You Have Experience with Medicaid payment integrity, claims analytics, fraud detection, program integrity, risk assessm