Medicaid/Medicare Program Integrity Analyst II

CoventBridge Integrity Systems•,

1d•$70,000 - $77,000•Remote

About The Position

The Medicaid/Medicare Program Integrity Analyst II evaluates and develops leads, complaints, and investigations to verify allegations of potential fraud and recommends or implements appropriate administrative actions. The role contributes to CoventBridge Integrity Systems’ objective of improving healthcare delivery by identifying and eliminating fraud, waste, and abuse. The position reports directly to the Program Integrity Supervisor and is based in the Grove City, Ohio office, or remotely from a home office for candidates who are not local. The analyst reviews Medicare and Medicaid claims and provider information, develops investigations, documents findings, prepares correspondence and reports, and collaborates with government agencies, other contractors, law enforcement, and stakeholders. The role may also include onsite audits and mentoring or training new Program Integrity staff.

Requirements

Excellent research, organization, prioritization, and time management skills.
Excellent verbal and written communication skills.
Ability to work independently with minimal supervision.
Ability to multitask in a fast-paced environment.
At least 1 year of experience in Program Integrity investigation or detection, or a related field demonstrating expertise in reviewing, analyzing or developing information, and making appropriate decisions.
High school diploma or GED equivalent.

Nice To Haves

College or technical degree coursework or completion in a field related to the position, such as Criminal Justice, Statistics, or Data Analysis.
Certified Fraud Examiner (CFE) certification; candidates with this certification will receive priority consideration.
Knowledge of statistics, data analysis techniques, and PC skills.

Responsibilities

Evaluate and develop leads, complaints, and investigations to determine whether further investigation or administrative action is warranted.
Conduct independent reviews of situations that may involve fraud or abuse.
Use basic data analysis techniques to identify aberrancies in Medicare and Medicaid claims data, and develop leads and investigations from sources such as CMS, OIG, 1-800-MEDICARE, and fraud alerts.
Review claims processing system information, including claims history and provider files, to identify provider billing patterns, potential fraud or abuse, and vulnerabilities in Medicare and Medicaid policies; initiate appropriate action.
Make potential fraud determinations using internal guidelines, Medicare and Medicaid provider manuals and regulations, and the Social Security Act.
Compile and maintain documentation and information related to investigations, cases, and leads.
Participate in onsite audits in conjunction with investigation development.
Develop and prepare potential Fraud Alerts and program vulnerabilities for submission to CMS.
Share information about current fraud investigations with other Medicare contractors, state Medicaid agencies, law enforcement, and other applicable stakeholders.
Prepare and submit external correspondence and reports, including overpayment letters, fraud case referrals, suspensions, rebuttals, Medicare and Medicaid findings reports, and administrative action recommendations.
Submit suspension notifications to providers after suspension approval.
Prepare and submit ADR letters to providers associated with medical record requests or suspension overpayment determinations.
Mentor and train new Program Integrity staff.
Perform other duties assigned by the PI Supervisor or PI Manager that contribute to task order goals and objectives.