Job Summary:
The Special Investigations Unit (SIU) Investigator Lead is the face of the SIU with external federal and state regulatory agencies and is responsible for regulatory communications to ensure timeliness with these oversight agencies. This role is also responsible for the identification and monitoring of emerging FWA trends and conducting research and interactions on claims, industry and other sources (internal and external) of data and information to identify potential FWA and support ongoing fraud investigations. Utilizes a variety of data analytics platforms to mine large volumes of data to identify and mitigate fraudulent claim activity, discover patterns and anomalies in billing behavior. This is a high case load volume, fast paced environment.
Essential Functions:
Identify risks and guard against fraud, waste, and abuse by interacting with internal and external business partners through development and monitoring of the Annual Program Integrity Fraud, Waste and Abuse Plan
Develop and implement innovative best practices to align with future growth and ongoing regulatory oversight
Act as the Program Integrity liaison and ensure collaboration with state and federal agencies and facilitate accurate deployment and ongoing monitoring of state-specific regulations and ongoing partnership with state regulators in managing Medicaid and Medicare programs
Engage in external fraud associations, forming relationships with industry leads, (i.e. other MCEs, NHCAA, etc.)
Predict emerging fraud, waste and abuse trends and communicate strategy to monitor and identify risk to CareSource
Identify opportunities for cost avoidance through prepayment review, provider education, or other preventative measures
Responsible for regulatory reporting accuracy and other ad hoc regulatory inquiries
Ensure that the team is submitting a consistent high volume of quality FWA referrals to our state partners
Lead investigation on-sites and serve as a mentor for the team
Conduct and assist investigators with complex investigations
Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling
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. Trend data to identify potential opportunities (e.g., variances, significant outliers, percentile ranked groups) for quality improvement or focused investigations
Identify trends and patterns using standard corporate processes, tools, reports, and databases, as well as leveraging other processes and data sources such as policies, coding guidelines, and regulations that would support the hypothesis being developed
Manage and decision claims pended for investigative purposes
Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types
Prepare and conduct in-depth complex interviews relevant to investigative plan
Execute and manage provider formal corrective action plans
Participate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case development
Participate 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 litigation
Aid in design data analysis strategies to identify potential areas for quality improvement or focused investigation
Monitor various media, state and federal press releases to identify emerging schemes and any potential impact and/or exposure
Lead and participate in all information sharing activities and produce actionable data analyses from information obtained
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 Fraud & Abuse Investigations required
Master's Degree (e.g., Criminal Justice, public health, mathematics, statistics, experimental psychology, epidemiology, health economics, nursing) preferred
Minimum of 10 (ten) years of experience in Healthcare Fraud, Healthcare data analysis, or Compliance required
Previous Law Enforcement experience preferred
Competencies, Knowledge and Skills:
Proven analytic skills in solving multi-dimensional problems
Advanced level experience in Microsoft Applications, including Excel, Access, Word and PowerPoint
SAS and SQL skills and experience for analytics projects, including database queries preferred
OIG/ FBI/MFCU knowledge and experience
Knowledge of inferential statistics
Working knowledge of descriptive statistical application and techniques
Critical listening, thinking skills, and verbal and written communication skills
Decision making/problem solving skills
Ability to work independently and within a team environment
Knowledge of multiple Medicaid, Medicare and managed care plans
Strong Knowledge of inpatient and outpatient coding standards, billing rules and regulations and knowledge of procedure and diagnosis codes (CPT, ICD10 coding, HCPCS, APC and DRGs)
Knowledge of value-based... For full info follow application link.
CareSource is an equal opportunity employer and gives consideration for employment to qualified applicants without regard to race, color, religion, sex, age, national origin, disability, sexual orientation, gender identity, genetic information, protected veteran status or any other characteristic protected by applicable federal, state or local law.
