Medicaid Claims Processing Remote Jobs (NOW HIRING)

BerryDunn is seeking a Senior Consultant with subject matter expertise in Medicaid program integrity and claims audits to support Hawaii 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 BerryDunn 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, escalate 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, Hawaii, 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 Hawaii 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 escalate 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, workpapers, 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 workstreams.
• 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 confidentiality and data security expectations.

Preferred Qualifications/Experience:

• Experience supporting Medicaid fraud risk assessments, TPL, PERM, payment integrity, and public sector health program analytics.
• Experience reviewing or auditing a wide range of claims, including Medicaid medical, dental, behavioral health, and pharmacy.
• Experience coordinating across client stakeholders, vendor partners, project leadership, and cross-functional workstreams in a public sector or health and human services environment.
• Preference will be given to candidates with relevant certifications, such as Certified Professional Coder (CPC), Certified in Healthcare Compliance (CHC), Certified Professional Medical Auditor (CPMA)
• Audit and investigation related certification such as Certified Fraud Examiner (CFE), Certified Internal Auditor (CIA), or equivalent credentials are also considered.
• Experience with Jira, SQL, Power BI, Tableau, or comparable analytics and dashboarding tools for claims analysis, dashboard creation, and presentation.

The base salary range targeted for this role is $85,000 to $100,000. This salary range represents BerryDunn's good faith and reasonable estimate of the range of possible compensation at the time of posting. If an applicant possesses experience, education, or other qualifications in excess of the minimum requirements for this posting, that applicant is encouraged to apply and a final salary range may then be based on those additional qualifications; compensation decisions are dependent on the facts and circumstances of each case. The salary of the finalist selected for this role will be based on a variety of factors, including but not limited to, years of experience, depth of experience, seniority, merit, education, training, amount of travel, and other relevant business considerations.

Our people are what make BerryDunn special, and in return we strive to support our employees and help them thrive. Eligible employees have access to benefits that go beyond what's expected to support their physical, mental, career, social, and financial well-being. Visit our website for a complete list of benefits and a look into our culture: Experience BerryDunn.

We will ensure that individuals are provided reasonable accommodation to participate in the job application or interview process or perform essential job functions. Please contact careers@berrydunn.com to request an accommodation.

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace.

About BerryDunn

BerryDunn is the brand name under which Berry, Dunn, McNeil & Parker, LLC and BDMP Assurance, LLP, independently owned entities, provide services. Since 1974, BerryDunn has helped businesses, nonprofits, and government agencies throughout the US and its territories solve their greatest challenges. The firm's tax, advisory, and consulting services are provided by Berry, Dunn, McNeil & Parker, LLC, and its attest services are provided by BDMP Assurance, LLP, a licensed CPA firm. 

BerryDunn is a client-centered, people-first professional services firm with a mission to empower the meaningful growth of our people, clients, and communities. Led by CEO Sarah Belliveau, the firm has been recognized for its efforts in creating a diverse and inclusive workplace culture, and for its focus on learning, development, and well-being. Learn more at berrydunn.com.

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