Job Description

Job Summary:

The Special Investigations Unit (SIU) Investigator I is responsible for comprehensive review, examination, and analysis of assigned allegations of healthcare fraud, waste and abuse (FWA) by medical professionals, facilities, and members. Specific responsibilities may fluctuate to align with department priorities and may include any of the following essential functions.

Essential Functions:

• Support other departments to obtain information needed to support SIU investigative efforts
• Proactively use analytical skills to identify potential areas of FWA or areas of risk to FWA
• Provide case review progress and coordinate with SIU team members and management on recommendations for further actions and/or resolution
• Recommend and participate in development and implementation of internal SIU policies and procedures
• Assist in achieving and maintaining compliance with state and federal FWA compliance and other deadlines related to rules and regulations
• Assist with unit's efforts to increase fraud and abuse training and awareness to all employees, members, and providers
• Responsible for maintaining confidentiality of all sensitive investigative information
• Know and uphold the provisions of the Corporate Compliance Plan
• Perform any other job-related instructions as requested

Investigative Case Triage

• Triage, examine, and analyze all assigned allegations of healthcare fraud, waste and abuse by medical professionals, facilities, and members
• Conduct assigned case triage with high level of autonomy and include data analysis, record review, cross-company discussions, member/provider interviews, and member/provider education
• Use concepts and knowledge of CPT, ICD, HCPCS, DRG, REV coding rules to analyze provider claim submissions
• Contact members, pharmacies, providers and third parties via telephone interview and/or letter to validate claim submissions and clarify allegation of FWA
• Perform data mining utilizing FWA detection software to identify aberrancies and outliers
• Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules, and guidelines
• Collaborate with investigative team on appropriate support initiatives from triage activities

Investigative Case Support

• Provide support of delegative vendor investigations
• Monitor SIU issued Corrective Action Plans, Settlement Agreements, and Restitutions
• Ensure that credible allegations of fraud and state suspensions are actioned appropriately across the organization
• Generate SIU metrics as required
• Ensure compliance and documentation to support regulatory requirements
• Generate and analyze data to support cases on stand-down, prepay, or AUDP and document financials in the case
• Submit deconfliction and permission requests to our market partners to ensure regulatory compliance and investigative efficiency
• Support triaging and managing the fraud reporting mechanisms, including case input into SIU case tracking software
• Support investigators in case development such as records requests/reviews, letter generation, and documentation

Broker Case Support:

• Review allegations of inappropriate enrollment by brokers and coordinate with matrix partners to investigate and resolve these allegations
• Triage these cases, as appropriate, to the SIU for full investigation

Waiver Case Support:

• Review of all Incident Management System (IMS) documents and other tips received through CareSource fraud reporting mechanisms to determine if the allegation requires further review.
• Responsible for referring suspected fraud to market regulators and presenting facts of the referral and initiating claims adjustments, when appropriate.

Education and Experience:

• Associates Degree or equivalent years of relevant work experience in a healthcare-related field, law enforcement, or insurance is required
• Minimum of eighteen (18) months experience in medical coding, billing, auditing, data analytics, or related field is required

Competencies, Knowledge, and Skills:

• Intermediate computer skills consisting of Microsoft Excel, Access, Outlook, Word, and Power Point.
• Ability to present issues of concern alleging schemes or scams to commit FWA
• Ability to work independently and as a member of a team to deliver high quality work
• Ability to support heavy workload and meet critical regulatory guidelines
• Strong attention to detail
• Effective communication skills both written and verbally
• Knowledge of Medicaid and Medicare preferred
• Strong knowledge of medical terminology, medical diagnostic, procedural terms, and medical billing
• Effective Listening and Thinking Skills

Licensure and Certification:

• Certified Fraud Examiner (CFE) or Anti-Healthcare Fraud Investigator (AHFI) certification is preferred. If not currently certified, this certification should be attained within 1 year of hire date.
• NHCAA or other fraud and abuse investigation training is preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:
$53,400.00 - $85,600.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. 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.

Compensation Type:
Salary

Competencies:
- Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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