Integrity Subject Matter Expert; SME

Overview

Berry Dunn 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.

• 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 over payment 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,…