Senior Medical Audit Specialist

Agency/Division Information  

The Oklahoma Health Care Authority (OHCA) works to ensure Oklahomans have access to better health and better care. The agency’s core values include passion for purpose, trust and transparency, empowerment and accountability, best in class and outcome-driven, and servant leadership. As part of the interview process, candidates may be required to attend an in-person interview at our Oklahoma City office.  

Position Purpose  

The Senior Medical Audit Specialist plays a critical role in safeguarding the integrity of healthcare services by providing clinical expertise in conducting audits and investigations to combat fraud, waste, and abuse. This position ensures compliance with OHCA policies, state statutes, and federal regulations through detailed analysis of billed services and documentation. By collaborating with internal and external stakeholders, the Senior Medical Audit Specialist helps to promote accountability and transparency in billing practices, supporting the overall mission of the Oklahoma Health Care Authority to provide better health and care for Oklahomans. 

Essential Functions May Include:  

• Provide clinical expertise in conducting investigations and completing comprehensive clinical audits in an effort to combat fraud, waste, and abuse.    

• Ensure billing compliance with OHCA policy, state statutes, and federal regulations.  

• Performs analysis and evaluation of billed services including claims and documentation to ensure all HCA policy requirements are met and services are clinically/medically appropriate.   

• Collaborate with others across the unit, organization, and external entities to evaluate audit results and make referrals to appropriate parties.    

• Communicate audit findings to all stakeholders.    

• Represents the Provider Audits Unit before an Administrative Law Judge (ALJ) and in legal proceedings regarding any general provider appeals, in an informed and professional manner.   

• Maintain licensure and certifications.    

• Other duties as assigned.  

Supervisory Responsibilities: This position does not supervise.  

Knowledge, Skills, Abilities and Competency Requirements 

The Senior Medical Audit Specialist requires in-depth knowledge of healthcare policies, state and federal regulations, and audit processes, as well as the ability to analyze complex billing data and ensure compliance. Strong communication and collaboration skills are essential to effectively convey audit findings and work with various stakeholders. This role demands strategic problem-solving and organizational skills to manage multiple tasks and resolve complex issues.  

The best-fitting Korn Ferry competencies for this position include Ensures Accountability, as the role focuses on enforcing compliance and managing responsibilities, and Collaborates, given the need for cross-functional teamwork and stakeholder engagement.  

Education and/or Experience:  

• Possession of a valid permanent Oklahoma license as a Registered Nurse (RN) as approved by the Oklahoma Board of Nursing or Registered Nurse License recognized by the Enhanced Nurse Licensure Compact (eNLC) AND 

• 5 years of professional experience as a registered nurse.  

• There is no substitution for licensure.   

Preference Qualifications Include:  

• Certifications in any of the following areas: Certified Professional Medical Auditor (CPMA), Certified Professional Coder (CPC)  

• General understanding of coding principles (CPT, HCPCS, ICD-10 and /or DRG)  

• Experience with Medicaid and Medicare billing audits  

• Experience in medical review, auditing, utilization review, compliance or regulatory work.   

Physical Demands and Work Environment 

Work is typically performed in an office setting with climate-controlled settings and exposure to moderate noise levels. In the course of performing job duties, employees are required to speak, stand, walk, and reach with their hands and arms. This position requires extended periods of sitting and daily use of computers and phones. Employees must be willing to complete all job-related travel associated with this position. Being present at the office is an essential function of this position.  

Accommodation Statement