CareSource
Program Integrity Investigator III
CareSource, Dayton, Ohio, United States, 45402
Job Summary:The Special Investigations Unit (SIU) III is responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professional, facilities, and members. Researches, gathers, and analyzes data to identify trends, patterns, aberrancies, and outliers in provider billing behavior. Serves as a subject matter expert for other investigators.
Essential Functions:Develop, coordinate and conduct strategic fact-driven investigative projects including business process review, execution of investigative activities, and development of investigation outcome recommendationsManage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data and translate analytical findings into actionable itemsManage strategic investigative plan and drive investigative outcome for the teamEnsure quality outcomes for investigative team through auditing and oversightPrioritize, track, and report status of investigationsReport identified corporate financial impact issuesUse concepts and knowledge of coding guidelines to analyze complex provider claim submissionsResearch, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelinesIdentify, research and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approachCollaborate with data analytics team and utilize RAT STATS on Statistically Valid Random SamplingCoordinate on-site and desk audits of medical record reviews and claim auditsManage and decision claims pended for investigative purposesMaintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty typesPrepare and conduct in-depth complex interviews relevant to investigative planExecute and manage provider formal corrective action plansParticipate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case developmentParticipate in meetings with Legal General Counsel to drive case legal actions, formal corrective actions, negotiations with recovery efforts, settlement agreements, and preparation of evidentiary documents for litigationDevelop regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agenciesManage and maintain sensitive confidential investigative informationPresent, support, and defend investigative research to seek approval for formal corrective actionsEstablish and maintain relationships with Federal and State law enforcement agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and preventionSME in the designated market and ability to apply external intelligence to their analysis and case developmentDevelop and present internal and external formal presentationsAttend fraud, waste, and abuse training/conferencesMaintain compliance with state and federal laws and regulations, and contractsAdhere to the CareSource Corporate Compliance Plan and the Anti-Fraud PlanAssist in Federal and State regulatory audits as neededPerform any other job related instructions as requested
Education and Experience:Bachelor's Degree or equivalent years of relevant work experience in Health-Related Field, Law Enforcement, or Insurance requiredMaster's Degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing) preferredMinimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics or related field is required
Competencies, Knowledge and Skills:Intermediate proficiency level in Microsoft Office to include Outlook, Word, Excel, Access, and PowerPointEffective listening and critical thinking skills and the ability to identify gaps in logicStrong interpersonal skills, high level of professionalism, integrity and ethics in performance of all dutiesExcellent problem solving and decision making skills with attention to detailsBackground in research and drawing conclusionsAbility to perform intermediate data analysis and to articulate understanding of findingsAbility to work under limited supervision with moderate latitude for initiative and independent judgmentAbility to manage demanding investigative case loadAbility to develop, prioritize and accomplish goalsSelf-motivated, self-directedStrong written skills with ability to compose detailed investigative reports and professional internal and external correspondencesPresentation experienceKnowledge of Medicaid, Medicare, healthcare rules preferredBackground in medical terminology, CPT, HCPCS, ICD codes or medical billing preferredComplex project management skills preferredDisplay leadership qualities
Licensure and Certification:Accredited Healthcare Fraud Investigator (AHFI) orCertified Fraud Examiner (CFE), and Certified Professional Coder (CPC) certifications are requiredNHCAA or other fraud and abuse investigation training is preferred
Working Conditions:General office environment; may be required to sit or stand for extended periods of timeOccasional travel (up to 10%) to attend meetings, training, and conferences may be required
Compensation Range:$69,400.00 - $111,000.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.Compensation Type:SalaryCompetencies:- Create an Inclusive Environment- Cultivate Partnerships- Develop Self and Others- Drive Execution- Influence Others- Pursue Personal Excellence- Understand the BusinessThis job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.
Essential Functions:Develop, coordinate and conduct strategic fact-driven investigative projects including business process review, execution of investigative activities, and development of investigation outcome recommendationsManage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data and translate analytical findings into actionable itemsManage strategic investigative plan and drive investigative outcome for the teamEnsure quality outcomes for investigative team through auditing and oversightPrioritize, track, and report status of investigationsReport identified corporate financial impact issuesUse concepts and knowledge of coding guidelines to analyze complex provider claim submissionsResearch, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelinesIdentify, research and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approachCollaborate with data analytics team and utilize RAT STATS on Statistically Valid Random SamplingCoordinate on-site and desk audits of medical record reviews and claim auditsManage and decision claims pended for investigative purposesMaintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty typesPrepare and conduct in-depth complex interviews relevant to investigative planExecute and manage provider formal corrective action plansParticipate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case developmentParticipate in meetings with Legal General Counsel to drive case legal actions, formal corrective actions, negotiations with recovery efforts, settlement agreements, and preparation of evidentiary documents for litigationDevelop regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agenciesManage and maintain sensitive confidential investigative informationPresent, support, and defend investigative research to seek approval for formal corrective actionsEstablish and maintain relationships with Federal and State law enforcement agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and preventionSME in the designated market and ability to apply external intelligence to their analysis and case developmentDevelop and present internal and external formal presentationsAttend fraud, waste, and abuse training/conferencesMaintain compliance with state and federal laws and regulations, and contractsAdhere to the CareSource Corporate Compliance Plan and the Anti-Fraud PlanAssist in Federal and State regulatory audits as neededPerform any other job related instructions as requested
Education and Experience:Bachelor's Degree or equivalent years of relevant work experience in Health-Related Field, Law Enforcement, or Insurance requiredMaster's Degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing) preferredMinimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics or related field is required
Competencies, Knowledge and Skills:Intermediate proficiency level in Microsoft Office to include Outlook, Word, Excel, Access, and PowerPointEffective listening and critical thinking skills and the ability to identify gaps in logicStrong interpersonal skills, high level of professionalism, integrity and ethics in performance of all dutiesExcellent problem solving and decision making skills with attention to detailsBackground in research and drawing conclusionsAbility to perform intermediate data analysis and to articulate understanding of findingsAbility to work under limited supervision with moderate latitude for initiative and independent judgmentAbility to manage demanding investigative case loadAbility to develop, prioritize and accomplish goalsSelf-motivated, self-directedStrong written skills with ability to compose detailed investigative reports and professional internal and external correspondencesPresentation experienceKnowledge of Medicaid, Medicare, healthcare rules preferredBackground in medical terminology, CPT, HCPCS, ICD codes or medical billing preferredComplex project management skills preferredDisplay leadership qualities
Licensure and Certification:Accredited Healthcare Fraud Investigator (AHFI) orCertified Fraud Examiner (CFE), and Certified Professional Coder (CPC) certifications are requiredNHCAA or other fraud and abuse investigation training is preferred
Working Conditions:General office environment; may be required to sit or stand for extended periods of timeOccasional travel (up to 10%) to attend meetings, training, and conferences may be required
Compensation Range:$69,400.00 - $111,000.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.Compensation Type:SalaryCompetencies:- Create an Inclusive Environment- Cultivate Partnerships- Develop Self and Others- Drive Execution- Influence Others- Pursue Personal Excellence- Understand the BusinessThis job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.