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Job Description
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.
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 PlanDevelop and implement innovative best practices to align with future growth and ongoing regulatory oversightAct 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 programsEngage 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 CareSourceIdentify opportunities for cost avoidance through prepayment review, provider education, or other preventative measuresResponsible for regulatory reporting accuracy and other ad hoc regulatory inquiriesEnsure that the team is submitting a consistent high volume of quality FWA referrals to our state partnersLead investigation on-sites and serve as a mentor for the teamConduct and assist investigators with complex investigationsCollaborate with data analytics team and utilize
RAT STATS
on Statistically Valid Random SamplingManage case turn-around times to promote efficiency in investigations and to mitigate risk to CareSourceMeet quality standards of case documentationGenerate 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 investigationsIdentify 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 developedManage and decision claims pended for investigative purposesMaintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty typesPrepare and conduct in-depth complex interviews relevant to investigative planExecute and manage provider formal corrective action plansParticipate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case developmentParticipate 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 litigationAid in design data analysis strategies to identify potential areas for quality improvement or focused investigationMonitor various media, state and federal press releases to identify emerging schemes and any potential impact and/or exposureLead and participate in all information sharing activities and produce actionable data analyses from information obtainedManage and maintain sensitive confidential investigative informationMaintain compliance with state and federal laws and regulations and contractsAdhere to the CareSource Corporate Compliance Plan and the Anti-Fraud PlanAssist in Federal and State regulatory audits, as neededPerform any other job-related instructions, as requested
Education and Experience:
Bachelor's Degree or equivalent years of relevant work experience in Fraud & Abuse Investigations requiredMaster's Degree (e.g., Criminal Justice, public health, mathematics, statistics, experimental psychology, epidemiology, health economics, nursing) preferredMinimum of 10 (ten) years of experience in Healthcare Fraud, Healthcare data analysis, or Compliance requiredPrevious Law Enforcement experience preferred
Competencies, Knowledge and Skills:
Proven analytic skills in solving multi-dimensional problemsAdvanced level experience in Microsoft Applications, including Excel, Access, Word and PowerPointSAS and SQL skills and experience for analytics projects, including database queries preferred
OIG/ FBI/MFCU
knowledge and experienceKnowledge of inferential statisticsWorking knowledge of descriptive statistical application and techniquesCritical listening, thinking skills, and verbal and written communication skillsDecision making/problem solving skillsAbility to work independently and within a team environmentKnowledge of multiple Medicaid, Medicare and managed care plansStrong 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 reimbursement methodologyAbility to lead analytic... 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.
