SoftDev
Program Integrity Analyst
SoftDev, Miami, Florida, us, 33222
SoftDev is seeking a qualified candidate to serve as a Program Integrity Analyst to join our team! SoftDev is performing Medicare and Medicaid Program Integrity work for the Centers for Medicare & Medicaid Services (CMS). The overall project includes data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse.
Position Overview:
The position is expected to perform high level complex investigations of medical professional service providers and develop cases for future action, including referral to law enforcement, education, over payment recovery and other administrative actions. Will work with internal resources and external agencies to develop cases and corrective actions as well as respond to requests for data and support. This position will work with the Southeast Unified Program Integrity Contractor which supports the following states: Florida, Georgia, Alabama, Tennessee, South Carolina, North Carolina, Virginia, West Virginia, and the territories of Puerto Rico and the US Virgin Islands.
An investigator uses good judgment and may work independently with minimum supervision and direction. The investigator also may work as part of a team as there may be times when the investigator needs to work with state and/or federal investigators and other personnel. An investigator handles multiple caseload assignments concurrently; organizes and analyzes complex evidentiary patterns; interviews and obtains statements from witnesses and others.
Investigators may also be required to complete complex investigative reports that apply regulations or rules to the program(s) affected by the behavior being investigated. There may also be times when the investigator will need to apply federal or state laws.
Investigators are expected to research and understand the relevant offenses being investigated; conduct efficient and effective investigations concerning those alleged offenses and detect or verify suspected violations; obtain information and evidence by observation, record examination, and interview. Investigators then analyze the results of the investigation to ascertain if the allegations have been corroborated and work with others to determine the appropriate steps that need to be taken to address the issues.
As part of an investigation, the investigator will need to prepare correspondence; be objective and accurate and communicate with others with tact. There may be times when investigators need to react to unplanned situations, be flexible in planning their activities and adopt effective courses of action.
As investigators will be working with health privacy information, they also must maintain confidentiality and understand all the laws, rules and regulations concerning health privacy.
Prerequisites:
US Citizen or Green CardholderBS 5-7 Years, MS 3-5, PhD 0-2Three to five years investigative experience preferredStrong investigative skillsStrong communication and organization skillsExperience in reviewing claims for technical requirements, performing medical review, and/or developing fraud casesStrong PC knowledge and skillsMust pass a drug screeningMust pass a criminal background checkMust reside in any of the following states: Florida, Georgia, Alabama, Tennessee, South Carolina, North Carolina, Virginia, or West VirginiaDesirable Qualifications - The most competitive candidates will have:
Strong background in investigationsKnowledge of investigative practices regarding healthcare providersKnowledge of Medicare and/or Medicaid programs and the rules, regulations, policies and proceduresBackground in evaluating, reviewing and analyzing medical claims and recordsAbility to learn and operate a variety of data systems, equipment and tools used in investigationsEssential Functions:
This position may require the incumbent to appear in court to testify about work findingsAbility to perform research and draw conclusionsAbility to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the GovernmentAbility to organize a case file, accurately and thoroughly document all steps takenAbility to compose correspondence, reports and referral summary lettersAbility to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard mattersAbility to communicate effectively, internally and externallyAbility to interpret laws and regulationsAbility to handle confidential materialAbility to report work activity on a timely basisAbility to work independently and as a member of a team to deliver high quality workAbility to attend meetings, training, and conferences, overnight travel required
SoftDev is strongly committed to the policies and principles of Equal Employment Opportunity (EEO), Employment decisions and practices, including but not limited to recruitment, selection, job assignment, transfer, promotion, discipline, training, compensation and benefits will be made without regard to race, color, religious creed, national origin, sex, citizenship, genetic information, marital status, age, sexual orientation, disability and/or US Veteran status, in accordance with applicable Federal, State, and Local laws. SoftDev is an Equal Opportunity / Affirmative Action Employer.
Position Overview:
The position is expected to perform high level complex investigations of medical professional service providers and develop cases for future action, including referral to law enforcement, education, over payment recovery and other administrative actions. Will work with internal resources and external agencies to develop cases and corrective actions as well as respond to requests for data and support. This position will work with the Southeast Unified Program Integrity Contractor which supports the following states: Florida, Georgia, Alabama, Tennessee, South Carolina, North Carolina, Virginia, West Virginia, and the territories of Puerto Rico and the US Virgin Islands.
An investigator uses good judgment and may work independently with minimum supervision and direction. The investigator also may work as part of a team as there may be times when the investigator needs to work with state and/or federal investigators and other personnel. An investigator handles multiple caseload assignments concurrently; organizes and analyzes complex evidentiary patterns; interviews and obtains statements from witnesses and others.
Investigators may also be required to complete complex investigative reports that apply regulations or rules to the program(s) affected by the behavior being investigated. There may also be times when the investigator will need to apply federal or state laws.
Investigators are expected to research and understand the relevant offenses being investigated; conduct efficient and effective investigations concerning those alleged offenses and detect or verify suspected violations; obtain information and evidence by observation, record examination, and interview. Investigators then analyze the results of the investigation to ascertain if the allegations have been corroborated and work with others to determine the appropriate steps that need to be taken to address the issues.
As part of an investigation, the investigator will need to prepare correspondence; be objective and accurate and communicate with others with tact. There may be times when investigators need to react to unplanned situations, be flexible in planning their activities and adopt effective courses of action.
As investigators will be working with health privacy information, they also must maintain confidentiality and understand all the laws, rules and regulations concerning health privacy.
Prerequisites:
US Citizen or Green CardholderBS 5-7 Years, MS 3-5, PhD 0-2Three to five years investigative experience preferredStrong investigative skillsStrong communication and organization skillsExperience in reviewing claims for technical requirements, performing medical review, and/or developing fraud casesStrong PC knowledge and skillsMust pass a drug screeningMust pass a criminal background checkMust reside in any of the following states: Florida, Georgia, Alabama, Tennessee, South Carolina, North Carolina, Virginia, or West VirginiaDesirable Qualifications - The most competitive candidates will have:
Strong background in investigationsKnowledge of investigative practices regarding healthcare providersKnowledge of Medicare and/or Medicaid programs and the rules, regulations, policies and proceduresBackground in evaluating, reviewing and analyzing medical claims and recordsAbility to learn and operate a variety of data systems, equipment and tools used in investigationsEssential Functions:
This position may require the incumbent to appear in court to testify about work findingsAbility to perform research and draw conclusionsAbility to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the GovernmentAbility to organize a case file, accurately and thoroughly document all steps takenAbility to compose correspondence, reports and referral summary lettersAbility to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard mattersAbility to communicate effectively, internally and externallyAbility to interpret laws and regulationsAbility to handle confidential materialAbility to report work activity on a timely basisAbility to work independently and as a member of a team to deliver high quality workAbility to attend meetings, training, and conferences, overnight travel required
SoftDev is strongly committed to the policies and principles of Equal Employment Opportunity (EEO), Employment decisions and practices, including but not limited to recruitment, selection, job assignment, transfer, promotion, discipline, training, compensation and benefits will be made without regard to race, color, religious creed, national origin, sex, citizenship, genetic information, marital status, age, sexual orientation, disability and/or US Veteran status, in accordance with applicable Federal, State, and Local laws. SoftDev is an Equal Opportunity / Affirmative Action Employer.