• Conduct Quality Management Reviews (QMRs) and support Performance Improvement Projects (PIPs) • Conduct on-site and desk audits to ensure services comply with DMAS regulations, Medicaid policy, service limits, medical necessity requirements, and provider qualifications • Review medical records, billing patterns, and service documentation to assess compliance and identify inconsistencies or potential fraud • Analyze utilization trends and exception reports to identify outliers or inappropriate billing practices • Lead provider engagement activities, including documentation requests, exit conferences, and explanation of findings and corrective actions • Prepare accurate audit documentation, summaries, and referrals as needed • Lead validation and evaluation of PIPs in clinical & non-clinical areas per CMS EQR Protocols 3 & 7 • Design and refine study topics, aims, populations, sampling methods, indicators, and data collection plans • Conduct statistical analysis on claims, encounter, and survey data; interpret findings accurately • Guide and support market through PIP planning and implementation with best practices and data-driven interventions • Facilitate stakeholder focus groups and technical assistance sessions • Create comprehensive deliverables: protocols, validation assessments, technical reports, improvement plans, and presentations • Maintain project timelines, coordinate subcontractors, and track deliverables