Job Summary:
The Special Investigations Unit (SIU) Investigator II is responsible for investigating and resolving moderate complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professional, facilities, and members.
Essential Functions:
- Conduct investigations on own initiative or at the request of management; investigation includes data analysis, record review, cross company discussions, onsite audits, member/provider interviews, coordination with legal representative, and legal case preparation
- Perform data mining utilizing fraud, waste and abuse detection software to identify aberrancies and outliers
- Maintain accurate, current, and thorough case information in SIU’s case tracking system
- Provide updates and reports on investigation cases’ progress and coordinates with SIU team members and management on recommendations, developing investigative plans, further actions and/or resolution
- Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling Work with the clinical review team to compare medical records to bills submitted for payment looking at documentation compared to billing guidelines
- Coordinate and conduct on-site and desk audits of medical record reviews and claim audits
- Manage case turn-around times to promote efficiency in investigations and to mitigate risk to CareSource
- Meet quality standards of case documentation
- Generate leads in our fraud detection system to result in investigations that will prevent risk to CareSource
- Examine abnormal claims and billing trends to detect and investigate FWA
- Apply subject-matter knowledge to solve common and complex investigations
- Arrange and conduct meetings with providers, provider employees, business partners and where appropriate, representatives from regulatory agencies and law enforcement in the conduction of investigations
- Contact members, pharmacies, providers and third parties via telephone interview and/or letter to validate claim submissions and clarify allegation of FWA
- Participate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case development
- Responsible for maintaining confidentiality of all sensitive investigative information
- Develop and maintain contacts/liaison with law enforcement, regulatory agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention
- Prepare summary and/or detailed reports on investigative findings and/or referrals to state and federal agencies to include, but not limited to, the MEDIC, FBI, Attorney General MFCU, HHS-OIG, MDCH, ODJFS, CMS and local law enforcement
- Create, prepare and present external, formal presentations including, but not limited to, local and national fraud training conferences, law enforcement and other agencies
- Assist in achieving and maintaining compliance with state and federal FWA compliance and other rules and regulations
- Proactively use analytical skills to identify potential areas of FWA or areas of risk to FWA and develop investigative plans for solutions
- Manage and maintain sensitive confidential investigative information
- Maintain compliance with state and federal laws and regulations and contracts
- Adhere to the CareSource Corporate Compliance Plan and the Anti-Fraud Plan
- Assist in Federal and State regulatory audits, as needed
- Perform 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 required
- Minimum of three (3) 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 computer skills consisting of Microsoft Excel, Access, Outlook, Word, and Power Point.
- Ability to perform research and draw conclusions
- Ability to present issues of concern alleging schemes or scams to commit FWA
- Ability to organize a case file, accurately and thoroughly document all steps taken
- Ability to report work activity on a timely basis
- Ability to work independently and as a member of a team to deliver high quality work.
- Ability to support heavy workload and meet critical regulatory guidelines
- Ability to compose correspondence, and prepare recommendations, reports, and referral summaries.
- Ability to communicate effectively, internally and externally
- Presentation skills necessary
- Knowledge of Medicaid and Medicare preferred
- Strong knowledge of medical terminology, medical diagnostic, procedural terms, and medical billing
- Critical Listening and Thinking Skills
- Works on problems/projects of diverse complexity and scope
Licensure and Certification:
- One of the following certifications are required: Certified Fraud Examiner (CFE), Anti-Healthcare Fraud Investigator (AHFI), or Certified Professional Coder (CPC)
- NHCAA 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 time
- Occasional travel (up to 10%) to attend meetings, training, and conferences may be required
Compensation Range:
$62,700.00 - $100,400.00
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. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
This 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 environment of belonging that welcomes and supports individuals of all backgrounds.
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