SIU Investigator III (Must live in Georgia)

CareSource

10d

About The Position

Job Summary: The Special Investigations Unit (SIU) III is responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professional, facilities, and members. Researches, gathers, and analyzes data to identify trends, patterns, aberrancies, and outliers in provider billing behavior. Serves as a subject matter expert for other investigators. Must live in Georgia. Essential Functions: Develop, coordinate and conduct strategic fact-driven investigative projects including business process review, execution of investigative activities, and development of investigation outcome recommendations Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data and translate analytical findings into actionable items Manage strategic investigative plan and drive investigative outcome for the team Ensure quality outcomes for investigative team through auditing and oversight Prioritize, track, and report status of investigations Report identified corporate financial impact issues Use concepts and knowledge of coding guidelines to analyze complex provider claim submissions Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines Identify, research and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approach Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling Coordinate and conduct on-site and desk audits of medical record reviews and claim audits 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 Present, support, and defend investigative research to seek approval for formal corrective actions Establish and maintain relationships with Federal and State law enforcement agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention SME in the designated market and ability to apply external intelligence to their analysis and case development Develop and present internal and external formal presentations, as needed Attend fraud, waste, and abuse training/conferences, as needed Support regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agencies 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

Requirements

Bachelor’s Degree or equivalent years of relevant work experience in Health-Related Field, Law Enforcement, or Insurance required
Minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics or related field is required
Intermediate proficiency level in Microsoft Office to include Outlook, Word, Excel, Access, and PowerPoint
Effective listening and critical thinking skills and the ability to identify gaps in logic
Strong interpersonal skills, high level of professionalism, integrity and ethics in performance of all duties
Excellent problem solving and decision making skills with attention to details
Background in research and drawing conclusions
Ability to perform intermediate data analysis and to articulate understanding of findings
Ability to work under limited supervision with moderate latitude for initiative and independent judgment
Ability to manage demanding investigative case load
Ability to develop, prioritize and accomplish goals
Self-motivated, self-directed
Strong written skills with ability to compose detailed investigative reports and professional internal and external correspondences
One of the following certifications is required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)
Must live in Georgia

Nice To Haves

Master’s Degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing) preferred
Presentation experience, beneficial
Knowledge of Medicaid, Medicare, healthcare rules preferred
Background in medical terminology, CPT, HCPCS, ICD codes or medical billing preferred
Complex project management skills preferred
Certified Professional Coder (CPC) is preferred
NHCAA or other fraud and abuse investigation training is preferred

Responsibilities

Develop, coordinate and conduct strategic fact-driven investigative projects including business process review, execution of investigative activities, and development of investigation outcome recommendations
Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data and translate analytical findings into actionable items
Manage strategic investigative plan and drive investigative outcome for the team
Ensure quality outcomes for investigative team through auditing and oversight
Prioritize, track, and report status of investigations
Report identified corporate financial impact issues
Use concepts and knowledge of coding guidelines to analyze complex provider claim submissions
Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines
Identify, research and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approach
Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling
Coordinate and conduct on-site and desk audits of medical record reviews and claim audits
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
Present, support, and defend investigative research to seek approval for formal corrective actions
Establish and maintain relationships with Federal and State law enforcement agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention
SME in the designated market and ability to apply external intelligence to their analysis and case development
Develop and present internal and external formal presentations, as needed
Attend fraud, waste, and abuse training/conferences, as needed
Support regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agencies
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