Compliance Specialist, Healthcare

Overview

DPHHS has a career opportunity within the Office of Inspector General, Program Compliance Bureau.

The Compliance Specialist 2 is responsible for identifying and investigating potential fraud, waste, and abuse within Montana Medicaid and HMK programs. Key duties include analyzing medical claims data, evaluating provider billing practices, and ensuring compliance with applicable state and federal regulations. The position requires interpreting healthcare policy, conducting provider interviews, calculating over payments, and referring fraud cases to appropriate agencies. Additional responsibilities include educating providers on proper billing procedures, responding to inquiries, and maintaining comprehensive case documentation.

• Identify and investigate potential fraud, waste, and abuse within Montana Medicaid and HMK programs.
• Analyze medical claims data and evaluate provider billing practices to ensure compliance with state and federal regulations.
• Interpret healthcare policy, conduct provider interviews, calculate over payments, and refer fraud cases to appropriate agencies.
• Educate providers on proper billing procedures, respond to inquiries, and maintain comprehensive case documentation.

• Knowledge of Medicaid rules, medical claims processing, medical terminology and coding principles and practices.
• Knowledge of reviewing, investigation, and research.
• Knowledge of Health Information Portability and Accountability Act (HIPAA) compliance.
• Ability to provide presentations to small groups.
• Ability to perform math calculations.
• Strong analytical and critical thinking skills.
• Meet minimum qualifications:
• Bachelor’s degree in health sciences, health information, accounting, business, or social sciences related field.
• Two years of experience with medical claims, medical coding, or medical review of services.
• Other combinations of directly related education and experience may be considered on a case-by-case basis.
• Preferred:
  Coding certification through American Health Information Management Association (AHIMA) or American Academy of Professional Coder (AAPC).

To be considered for a DPHHS position, submit the required documents with your application on the State of Montana Careers website. When submitting the required documents, you must check the "relevant document" box to ensure your attachments are uploaded correctly to your application for this position.

• Cover Letter
• Resume

Successful applicants will be subject to background checks relevant to the position and must pass reference checks before an offer will be extended. DPHHS is an equal opportunity employer. Women, minorities, and people with disabilities are encouraged to apply. For a copy of the full job description or if you need a reasonable accommodation in the application or hiring process, contact DPHHS Human Resources listed below.

This position may be eligible for partial telework within the state of Montana. Specific conditions will be provided by the supervisor and must adhere to state policy.

This position is open until filled with frequent screening of applicants.