Job Title
Medical Program Specialist 3 (MPS3/DAIO) – 71029080
Overview
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 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.
About the Division
The Division of Audit, Integrity, and Oversight (DAIO) is responsible for providing oversight and ensuring the integrity of our healthcare purchasing and grant activities. This includes auditing medical and other benefit providers and beneficiaries, preventing and investigating fraud, waste, and abuse, monitoring grant subrecipients, managing care organization contract monitoring, PEBB/SEBB monitoring, and overseeing 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. The position serves as an agency expert in medical coding, focusing on identifying risks, vulnerabilities, and potential fraud, waste, and abuse within agency programs. The role works with program managers, subject matter experts, clinicians, auditors, and fraud investigators to analyze complex health data, policies, and guidelines, and to create actionable intelligence.
The position is eligible for telework and is typically not required to report on-site. The default assigned work location for all Health Care Authority positions is within the State of Washington, and this position reports to Olympia, WA. Frequency of on‑site work is determined by business and operational needs. All agency employees are required to report to Olympia on their first and last days of employment to pick up and return state‑issued equipment, regardless of telework status or location.
Key Responsibilities
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 other stakeholders 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, ensuring 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 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 Administrator (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 Professional Coder (CPC).
Required Experience Options
Option 1: Master’s degree 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 in a related 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/non‑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.
Equal Opportunity & E‑Verify 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. All applicants with a legal right to work in the United States are encouraged to apply. HCA is an E‑Verify employer.
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