Senior Medical Audit Specialist

Recruitment #220511-UNCE-277


Position Description:
Act as the clinical specialist to the Provider Audits staff when analyzing traditional fee for service and managed care claims related to federal and state regulations.

*Provides clinical expertise in all Provider Audits regarding all general providers/issues.
*Performs verification of credentials of providers in conjunction with Provider Audits to ensure HCA policy requirements are met.
*Develops and maintains audit criteria for Provider Audits.
*Performs Provider Audits of billed services, including charges and documentation to ensure all HCA policy requirements are met and services are clinically/medically appropriate.
*Assists Provider Audits analyst in the evaluation and interpretation of billed charges and clinical documentation to ensure all HCA policy requirements are met and services are clinically/medically appropriate.
*Develops and provides training related to issues identified by the Provider Audits staff as needed.
*Represents the Provider Audits Unit before an ALJ and in legal proceedings regarding any general provider appeals.
*Reviews audit results of providers performed by other state agencies and make Provider Audits referrals as appropriate.
*Makes a policy recommendation to the Policy Unit, as policy issues are identified during Provider Audits.
*May be required to provide expert testimony in court proceedings.
*Performs related work as required and assigned.

TRAVEL: Travel on an “as needed basis”. 

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. 

The requirements listed below are representative of the knowledge, skill, and/or ability required. 

Adherence to work hours established for this position will allow for flexibility at the discretion of the supervisor or unit director.  It is anticipated that an inability to attend on any given day due to illness, etc., will prompt a telephone call to the supervisor in a timely manner.  Request for annual leave will be submitted in writing with enough advance notice to enable appropriate unit staffing (excludes emergency situations).  A current valid license as a Registered Nurse in the State of Oklahoma.

Accommodation Statement
The Oklahoma Health Care Authority complies with applicable Federal civil rights laws and does not discriminate.  All qualified applicants will receive consideration for employment without regard to race, color, sex, religion, disability, age, national origin, or genetic information. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact the Civil Rights Coordinator at 405-522-7335.


- Current, valid RN license and
- 4 years clinical experience and
- At least 1 year experience in medical review, auditing, utilization review, compliance or regulatory work. 
- General understanding of coding principles (CPT, HCPCS, ICD-9-CM and/or DRG)

- SoonerCare experience
- Experience with claims review or billing
- Experience in auditing, QA/QI or utilization review
- Advanced education


Please read instructions carefully and include all required documents when you submit your application.

No additional information will be accepted after the application has been submitted.