Program Integrity Investigative Coordinator I

CareSource•Ohio WFH, OH

6d•$41,200 - $66,000•Onsite

About The Position

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. This role involves accurately loading Fraud, Waste & Abuse (FWA) referrals into the SIU Case Management System, analyzing allegation facts to determine case closure or escalation, and interviewing individuals to gather information for FWA investigations. The coordinator will review claims for irregular billing patterns, generate reports using fraud detection software, and conduct data analysis to assess financial exposure. Maintaining anonymity and confidentiality is crucial throughout the intake process. The role also includes identifying billing errors and overpayments, requesting medical records, assisting in the oversight of Delegated Entities, preparing documentation for state Medicaid agencies, attending investigative meetings, and supporting provider removals. Accuracy of database information in the Case Management System, in conjunction with Facets and the Medicaid Information Technology System, is a key responsibility, as is upholding the Corporate Compliance Plan.

Requirements

High School Diploma or GED is required
Minimum of three (3) years’ experience in a health care related field or Customer Service is required
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

Nice To Haves

Associate’s Degree in Health-Related Field, Law Enforcement, or Insurance is preferred
Health care experience preferred (medical/dental claims, auditing, medical office experience, etc.)

Responsibilities

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