Incident Management Investigator

CareSource • Dayton, OH

1d • $62,700 - $100,400 • Onsite

About The Position

The Incident Management Investigator conducts clinical case investigations related to incidents submitted to the incident management system. This role involves interviewing members, claimants, caregivers, and facility staff, as well as contacting providers, business partners, regulatory agencies, and law enforcement. The investigator develops member care plans, including education and corrective action plans, and collaborates with various internal departments such as Care Management, SIU, Pharmacy, Medical Management, Provider Relations, Claims, Internal Audit, Regulatory, and Legal. A key aspect of the role is developing and maintaining relationships with external contacts involved in fraud investigation, detection, and prevention. The investigator also proactively identifies potential areas of member concern, including fraud, waste, and abuse, and ensures departmental compliance with state, regulatory, and departmental deadlines. Additionally, the role involves recommending and participating in the development and implementation of internal departmental policies and procedures.

Requirements

• Associates degree required.
• Equivalent years of relevant work experience may be accepted in lieu of required education.
• Two (2) years of experience in healthcare operations, care coordination, escalation or management required.
• Intermediate proficiency level with Microsoft Outlook, Word, Excel, Power Point, and Access is required.
• Effective oral and written communication skills.
• Ability to perform thorough investigations, develop care plans and see case through resolution and closure; ability to maintain confidentiality.
• Ability to organize and prioritize daily workload & meet required deadlines.
• Ability to work independently and as a member of a team to deliver high quality work.
• Presentation skills necessary.
• Critical listening and thinking skills.

Nice To Haves

• Knowledge of Medicaid and Medicare, preferred.
• Knowledge of medical terminology, medical diagnostic, procedural terms, and instances of FWA.

Responsibilities

• Conducts clinical case investigations related to incidents submitted to the incident management system.
• Interviews member, claimant (if claimant is not the member), personal caregivers, facility staff and others.
• Contacts providers & their employees, business partners and representatives from regulatory agencies and law enforcement in the conduction of investigations.
• Develops member care plan including member and caregiver education and corrective action plans.
• Collaborates with internal departments including, but not limited to, Care Management, SIU, Pharmacy, Medical Management, Provider Relations, Claims, Internal Audit, Regulatory, and Legal.
• Develops and maintains contacts/liaison with business partners, law enforcement, regulatory agencies, state, other company staff and external contacts involved in fraud investigation, detection and prevention.
• Proactively uses analytical skills to identify all potential areas of member concern including fraud, waste and abuse.
• Responsible for assisting department in meeting all state, regulatory and departmental deadlines.
• Recommends and participates in development and implementation of internal departmental policies and procedures.
• Performs any other job related duties as requested.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree