Medicaid Program Integrity Senior Consultant

Overview

Berry Dunn is seeking a Senior Consultant with subject matter expertise in Medicaid program integrity and claims audits to support Hawaiʻi Med-QUEST's (MQD) Medicaid Program Integrity initiatives as a forensic analyst.

You will perform claims audits, document findings, and conduct forensic reviews and investigations investigative activities related to Medicaid medical, dental, behavioral health, pharmacy claims, as well as provider, member, financial, and operational data. You will work as part of the Berry Dunn Program Integrity team, and work closely with MQD Program Integrity staff, audit and TPL specialists, data analysts, compliance staff, vendor partners, and other workstream members to help identify risks, interpret policy, improve internal controls, elevate issues for leadership, and support recovery efforts.

This position offers flexibility in work location, including fully onsite, hybrid, or remote arrangements. The preferred location is Kapolei, Hawaiʻi, or the U.S. West Coast. Regardless of location,
the role requires availability during Hawaii Standard Time (HST) working hours
.

Travel expectations
:
This role requires travel approximately 30%–50% of the time, including travel to Hawaiʻi for onsite client meetings, release activities, training support, go-live readiness, and related project needs.

• Conduct detailed reviews of Medicaid claims and related provider, member, eligibility, financial, and operational data to identify, document, and elevate potential fraud, waste, abuse, improper payments, compliance issues, and operational risks.
• Review Medicaid claims for accuracy, compliance, reasonableness, and alignment with Medicaid policies, federal and state regulations, program requirements, and coding standards and guidance.
• Support the review of operational data related to provider management, member services, financial management, and TPL.
• Prepare audit and investigative documentation such as case summaries, findings, recommendations, work papers, and supporting materials for review by the Forensic Manager, Program Integrity staff, audit SMEs, and project leadership.
• Research, interpret, and apply Medicaid policies, program integrity requirements, and applicable regulations to support audit findings, investigative documentation, recommendations, and corrective action follow-up.
• Assist with development of controls, monitoring approaches, review protocols, audit tools, documentation standards, and process improvements to strengthen FWA detection and deterrence.
• Support development or updates to policies, procedures related to Medicaid program integrity.
• Assist in the development of training, knowledge transfer, and technical assistance for client staff related to program integrity.
• Use Jira, SharePoint, meeting notes, decision logs, and action item trackers to support transparent issue tracking, documentation, coordination, and follow-through across work streams.
• Support onsite planning, workgroup sessions, client leadership preparation, release activities, and related project needs in coordination with the Forensic Manager, project leadership, and workstream leads.

Key Tools and Systems:

• Jira for action items, risks, blockers, dependencies, audit follow-up, corrective action tracking, dashboard visibility, and project coordination.
• Microsoft Office products for development of documents, presentations, and deliverables
• Microsoft Excel, for audit support, validation, visualization, and reporting.
• SharePoint for project documentation, report templates, audit methodology, review protocols, version control, quality review, and knowledge management.
• Microsoft Teams and Outlook for meeting coordination, stakeholder communication, audit follow-up, training support, and client/vendor collaboration.
• Claims, eligibility, provider, member, TPL, payment integrity, and related Medicaid or vendor systems, as applicable.

• Minimum three (3) years of experience conducting Medicaid claims audits, investigations, and/or compliance reviews.
• Knowledge of Medicaid Program Integrity principles, FWA, provider oversight, payment integrity, TPL, claims audit, or cost avoidance concepts.
• Experience developing or supporting audit findings, corrective action plans, executive-ready reporting, analytical summaries, methodology documentation, quality checks, or recurring performance reports.
• Strong analytical, documentation, quality assurance, and stakeholder coordination skills.
• Experience using SharePoint, Microsoft Teams, Outlook, Excel, or comparable tools to manage action items, documentation, investigative follow-up, and project coordination.
• Bachelor’s degree or equivalent combination of education and applicable experience preferred.
• Ability to conduct research and analysis related to Medicaid policies, claims, provider oversight, payment integrity, and program integrity requirements.
• Ability to handle sensitive program, operational, provider, member, client, PII/PHI, and HIPAA-related information in alignment with…