Medical Program Specialist 3 (MPS3/DAIO)
State of Washington, Olympia, WA, United States
Medical Program Specialist 3 (MPS3/DAIO)
Job ID: 71029080
The primary responsibility of this position is to serve as the agency’s expert in medical coding and Medicaid program integrity. This work helps ensure that fraud, waste, and abuse is identified and improper payments are recovered. The level of expertise required for this work means that DAIO staff often serve as subject matter experts for the agency and others in a variety of areas related to medical and other benefits claims and billing.
All HCA employees will apply an equity lens to their work, which may include but is not limited to all analyses of core business and processes.
About the division
The Division of Audit, Integrity, and Oversight (DAIO) is responsible for providing oversight and helping ensure the integrity of our healthcare purchasing and grant activities. This includes auditing medical and other benefit providers and beneficiaries; the identification, prevention, and investigation of fraud, waste, and abuse; grant subrecipient monitoring; managed care organization contract monitoring; PEBB/SEBB monitoring; and the oversight of behavioral health and recovery spending.
About the position
This Medical Program Specialist 3 (MPS3) reports to the Healthcare Analytics and Insight (HAI) unit manager and is a lead. This position serves as an agency expert in medical coding, focusing on identifying risks, vulnerabilities, and potential fraud, waste, and abuse within agency programs. As a medical coding expert, this position will work with agency program managers, subject matter experts, other clinicians, auditors, and fraud investigators to analyze complex health data, policies, and guidelines, to create actionable intelligence.
This position is eligible to telework and is typically not required to report on-site. The default assigned work location of all Health Care Authority (HCA) positions – both on-site and telework eligible positions – is within the State of Washington. This position reports to Olympia, WA. Frequency of onsite work will vary based on business and operational needs. All agency employees are required to report on-site in Olympia on their first and last days of employment to pick up and return state‑issued equipment, regardless of telework status or location.
What you will do
Serve as the subject matter expert in medical coding, utilizing expertise in ICD, CPT, and HCPCS coding systems to ensure compliance with federal and state regulations.
Provide consultation and expert guidance to DAIO, CQCT, DBHR, and others on coding practices, risks, and standards.
Develop training and alerts for providers on common coding errors and issues.
Stay current on changes in coding standards, regulations, and laws, and ensure information is shared as appropriate.
Design and lead training programs focused on improving coding accuracy (ICD, CPT, and HCPCS) and fostering an understanding of program integrity fundamentals to reduce fraud, waste, and abuse within the system.
Facilitate training in classrooms, remote settings, or recorded environments to ensure appropriate delivery of content to meet target audience needs.
Track and coordinate continuous education opportunities for staff with coding certifications.
Develop audit guides and procedures to support auditors in their reviews, ensuring that they have clear and standard protocols for identifying improper payments and potential risks for fraud, waste, and abuse.
Plan, design, and lead the most complex or sensitive coding audits as assigned by the HAI manager in consultation with the Deputy Director.
Conduct internal quality control reviews of medical coding audits – review for accuracy and quality.
Required qualifications
Option 1:
Professional certification such as Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent.
Option 2:
Active credential as a certified medical coder under the American Health Information Management Association (AHIMA) – Registered Health Information Administration (RHIA) – Registered Health Information Technology (RHIT) – Certified Coding Specialist (CCS) or Certified Coding Specialist – Physician-based (CCS-P).
Option 3:
American Academy of Professional Coders (AAPC) – Certified Profession Coder (CPC).
Experience or Education Options:
Option 1:
Master’s degree with major study in public health, public administration, nursing, health administration, economics, business administration, or a closely allied field, plus three (3) years of supervisory or consultative experience in a health services program.
Option 2:
Bachelor’s degree with major study in public health, public administration, nursing, health administration, economics, business administration, or a closely allied field, plus five (5) years of supervisory or consultative experience in a health services program.
Option 3:
Nine (9) years of supervisory or consultative experience in a health services program.
Option 4:
One (1) year of experience as a Medical Program Specialist 2.
Option 5:
Two (2) years of experience as a Medical Program Specialist 1.
Required competencies
The ability to take action to learn and grow.
The ability to take action to meet the needs of others.
Preferred qualifications
Demonstrated experience providing medical coding training or education, including developing training materials, delivering instruction, or mentoring staff in correct application of CPT, HCPCS, and ICD coding standards.
Experience conducting or supervising coding compliance audits, including interpreting medical policies and procedural coding guidelines.
Experience designing or implementing provider education programs related to medical billing, documentation standards, or coding accuracy.
Expert level proficiency in ICD-10-CM/PCS, CPT, and HCPCS coding sets.
Understanding of CMS guidelines, National Correct Coding Initiative (NCCI) edits, and Medically Unlikely Edits (MUEs).
Demonstrated ability to analyze claims and encounter data to identify trends, outliers, and patterns suggestive of fraud, waste, and abuse.
Demonstrated ability to translate highly technical coding guidelines and state regulations into clear, easily understandable training materials and presentations for diverse audiences.
Ability to serve as an internal consultant to non-clinical
on-coding staff, providing guidance on guidelines and claim reviews.
Demonstrated initiative and ability to see a task through to the end.
Demonstrated ability to communicate effectively across multiple levels of the organization and with program customers and stakeholders.
Demonstrated planning and organizational skills.
Demonstrated proficiency in common software applications such as Microsoft Office (Project, Word, Excel, PowerPoint, Outlook, and PowerBI).
Strong written communication skills with the ability to create clear reports for non-technical audiences.
Demonstrated time and project management skills with the ability to develop and advance assigned projects from inception to completion.
Demonstrated ability to exercise professional independent judgment and reach sound decisions.
Demonstrated ability to contribute effectively to a team and participate in making team decisions.
The ability to take action to meet the needs of others.
Demonstrated ability to identify current and developing trends in medical healthcare delivery systems and billing.
Previous experience conducting peer reviews on the work of other auditors/coders, providing constructive feedback and targeted retraining to improve team accuracy.
How to apply
To apply for this position, you will need to complete your profile which includes three professional references and attach in separate files:
Cover letter that specifically addresses how you meet the qualifications for this position.
Current resume.
To take advantage of veteran preference, please do the following:
Attach a copy of your DD214 (Member 4 long-form copy), NGB 22, or USDVA signed verification of service letter.
Please black out any PII (personally identifiable information) data such as social security numbers. Include your name as it appears on your application in careers.wa.gov.
Notes
Prior to a new hire, a background check including criminal record history will be conducted. Information from the background check will not necessarily preclude employment.
Equal Opportunity & Diversity Statement
HCA is an equal opportunity employer. We value the importance of creating an environment in which all employees can feel respected, included, and empowered to bring unique ideas to the agency. HCA has five employee resource groups (ERGs). ERGs are voluntary, employee-led groups whose aim is to foster a diverse, inclusive workplace aligned with HCA’s mission. Our diversity and inclusion efforts include embracing different cultures, backgrounds and viewpoints while fostering growth and advancement in the workplace.
E-Verify Statement
The Washington State Health Care Authority (HCA) is an E-Verify employer. All applicants with a legal right to work in the United States are encouraged to apply.
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Job ID: 71029080
The primary responsibility of this position is to serve as the agency’s expert in medical coding and Medicaid program integrity. This work helps ensure that fraud, waste, and abuse is identified and improper payments are recovered. The level of expertise required for this work means that DAIO staff often serve as subject matter experts for the agency and others in a variety of areas related to medical and other benefits claims and billing.
All HCA employees will apply an equity lens to their work, which may include but is not limited to all analyses of core business and processes.
About the division
The Division of Audit, Integrity, and Oversight (DAIO) is responsible for providing oversight and helping ensure the integrity of our healthcare purchasing and grant activities. This includes auditing medical and other benefit providers and beneficiaries; the identification, prevention, and investigation of fraud, waste, and abuse; grant subrecipient monitoring; managed care organization contract monitoring; PEBB/SEBB monitoring; and the oversight of behavioral health and recovery spending.
About the position
This Medical Program Specialist 3 (MPS3) reports to the Healthcare Analytics and Insight (HAI) unit manager and is a lead. This position serves as an agency expert in medical coding, focusing on identifying risks, vulnerabilities, and potential fraud, waste, and abuse within agency programs. As a medical coding expert, this position will work with agency program managers, subject matter experts, other clinicians, auditors, and fraud investigators to analyze complex health data, policies, and guidelines, to create actionable intelligence.
This position is eligible to telework and is typically not required to report on-site. The default assigned work location of all Health Care Authority (HCA) positions – both on-site and telework eligible positions – is within the State of Washington. This position reports to Olympia, WA. Frequency of onsite work will vary based on business and operational needs. All agency employees are required to report on-site in Olympia on their first and last days of employment to pick up and return state‑issued equipment, regardless of telework status or location.
What you will do
Serve as the subject matter expert in medical coding, utilizing expertise in ICD, CPT, and HCPCS coding systems to ensure compliance with federal and state regulations.
Provide consultation and expert guidance to DAIO, CQCT, DBHR, and others on coding practices, risks, and standards.
Develop training and alerts for providers on common coding errors and issues.
Stay current on changes in coding standards, regulations, and laws, and ensure information is shared as appropriate.
Design and lead training programs focused on improving coding accuracy (ICD, CPT, and HCPCS) and fostering an understanding of program integrity fundamentals to reduce fraud, waste, and abuse within the system.
Facilitate training in classrooms, remote settings, or recorded environments to ensure appropriate delivery of content to meet target audience needs.
Track and coordinate continuous education opportunities for staff with coding certifications.
Develop audit guides and procedures to support auditors in their reviews, ensuring that they have clear and standard protocols for identifying improper payments and potential risks for fraud, waste, and abuse.
Plan, design, and lead the most complex or sensitive coding audits as assigned by the HAI manager in consultation with the Deputy Director.
Conduct internal quality control reviews of medical coding audits – review for accuracy and quality.
Required qualifications
Option 1:
Professional certification such as Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent.
Option 2:
Active credential as a certified medical coder under the American Health Information Management Association (AHIMA) – Registered Health Information Administration (RHIA) – Registered Health Information Technology (RHIT) – Certified Coding Specialist (CCS) or Certified Coding Specialist – Physician-based (CCS-P).
Option 3:
American Academy of Professional Coders (AAPC) – Certified Profession Coder (CPC).
Experience or Education Options:
Option 1:
Master’s degree with major study in public health, public administration, nursing, health administration, economics, business administration, or a closely allied field, plus three (3) years of supervisory or consultative experience in a health services program.
Option 2:
Bachelor’s degree with major study in public health, public administration, nursing, health administration, economics, business administration, or a closely allied field, plus five (5) years of supervisory or consultative experience in a health services program.
Option 3:
Nine (9) years of supervisory or consultative experience in a health services program.
Option 4:
One (1) year of experience as a Medical Program Specialist 2.
Option 5:
Two (2) years of experience as a Medical Program Specialist 1.
Required competencies
The ability to take action to learn and grow.
The ability to take action to meet the needs of others.
Preferred qualifications
Demonstrated experience providing medical coding training or education, including developing training materials, delivering instruction, or mentoring staff in correct application of CPT, HCPCS, and ICD coding standards.
Experience conducting or supervising coding compliance audits, including interpreting medical policies and procedural coding guidelines.
Experience designing or implementing provider education programs related to medical billing, documentation standards, or coding accuracy.
Expert level proficiency in ICD-10-CM/PCS, CPT, and HCPCS coding sets.
Understanding of CMS guidelines, National Correct Coding Initiative (NCCI) edits, and Medically Unlikely Edits (MUEs).
Demonstrated ability to analyze claims and encounter data to identify trends, outliers, and patterns suggestive of fraud, waste, and abuse.
Demonstrated ability to translate highly technical coding guidelines and state regulations into clear, easily understandable training materials and presentations for diverse audiences.
Ability to serve as an internal consultant to non-clinical
on-coding staff, providing guidance on guidelines and claim reviews.
Demonstrated initiative and ability to see a task through to the end.
Demonstrated ability to communicate effectively across multiple levels of the organization and with program customers and stakeholders.
Demonstrated planning and organizational skills.
Demonstrated proficiency in common software applications such as Microsoft Office (Project, Word, Excel, PowerPoint, Outlook, and PowerBI).
Strong written communication skills with the ability to create clear reports for non-technical audiences.
Demonstrated time and project management skills with the ability to develop and advance assigned projects from inception to completion.
Demonstrated ability to exercise professional independent judgment and reach sound decisions.
Demonstrated ability to contribute effectively to a team and participate in making team decisions.
The ability to take action to meet the needs of others.
Demonstrated ability to identify current and developing trends in medical healthcare delivery systems and billing.
Previous experience conducting peer reviews on the work of other auditors/coders, providing constructive feedback and targeted retraining to improve team accuracy.
How to apply
To apply for this position, you will need to complete your profile which includes three professional references and attach in separate files:
Cover letter that specifically addresses how you meet the qualifications for this position.
Current resume.
To take advantage of veteran preference, please do the following:
Attach a copy of your DD214 (Member 4 long-form copy), NGB 22, or USDVA signed verification of service letter.
Please black out any PII (personally identifiable information) data such as social security numbers. Include your name as it appears on your application in careers.wa.gov.
Notes
Prior to a new hire, a background check including criminal record history will be conducted. Information from the background check will not necessarily preclude employment.
Equal Opportunity & Diversity Statement
HCA is an equal opportunity employer. We value the importance of creating an environment in which all employees can feel respected, included, and empowered to bring unique ideas to the agency. HCA has five employee resource groups (ERGs). ERGs are voluntary, employee-led groups whose aim is to foster a diverse, inclusive workplace aligned with HCA’s mission. Our diversity and inclusion efforts include embracing different cultures, backgrounds and viewpoints while fostering growth and advancement in the workplace.
E-Verify Statement
The Washington State Health Care Authority (HCA) is an E-Verify employer. All applicants with a legal right to work in the United States are encouraged to apply.
#J-18808-Ljbffr