Program Integrity Investigative Coordinator I

CareSource • Full-time • Ohio WFH, United States of America • 1w ago

Job Summary:

The Program Integrity Investigative Coordinator I monitors and maintains all SIU fraud reporting mechanisms (hotline, facets routing, fax, emails) to ensure compliance with regulatory requirements.

Essential Functions:

Accurately load Fraud, Waste & Abuse (FWA) referrals into the SIU Case Management System
Analyze FWA allegation facts and evaluate whether cases can be closed or escalated
Interview claimants, providers, members or any other individuals to obtain information relevant to any FWA investigation
Review claims for irregular billing patterns, consulting specialists when necessary
Generate various reports utilizing multiple fraud detection software systems
Conduct rudimentary data analysis to determine financial exposure or risk to FWA allegation across all lines of business
Responsible for maintaining anonymity and confidentiality during all phases of intake process
Independently identify billing errors and accidental overpayments initiating corrective action through the Research and Resolution Submission portal
Request medical records on an as-needed basis and as directed by Team Lead; partner with Clinical staff to resolve any issues
Assist Program Integrity in the oversight of Delegated Entities by routing state directed correspondence and generating claims data reports across all lines of business
Prepare and document Attestations, De-conflictions and Additional Allegation FWA informational letters, as contractually required, for any state Medicaid agency
Attend state Medicaid investigative meetings to transcribe updates provided by the Attorney General’s Office; update any applicable cases
Support compliance and regulatory requirements by verifying all state/federal directed provider removals are completed accurately across all lines of business
Drive accuracy of database information maintained in Case Management System; proactively verify the accuracy of provider information in concert with Facets and the Medicaid Information Technology System
Know and uphold the provisions of the Corporate Compliance Plan
Perform any other job related instructions as requested

Education and Experience:

High School Diploma or GED is required
Associate’s Degree in Health-Related Field, Law Enforcement, or Insurance is preferred
Minimum of three (3) years’ experience in a health care related field or Customer Service is required
Health care experience preferred (medical/dental claims, auditing, medical office experience, etc.)

Competencies, Knowledge and Skills:

Intermediate computer skills consisting of Microsoft Excel, Access, Outlook, Word, and Power Point
Ability to navigate multiple software systems at a high proficiency level
Good communication skills
Ability to work independently and within a team environment
High attention to detail
Critical listening and thinking skills
Proper grammar usage
Time management skills
Proper phone etiquette
Customer service oriented
Decision making/problem solving skills
Strong organization skills
Customer service oriented

Licensure and Certification:

None

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

$41,200.00 - $66,000.00

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. 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):

Hourly

Organization Level Competencies