Healthcare Fraud Investigator III

2 weeks ago

Dayton, Ohio, United States CareSource Full time
Job Summary:

The Special Investigations Unit (SIU) III is responsible for conducting thorough investigations and resolving complex allegations of healthcare fraud, waste, and abuse (FWA) by medical professionals, facilities, and members. The successful candidate will research, gather, and analyze data to identify trends, patterns, and anomalies in provider billing behavior, serving as a subject matter expert for other investigators.

Key Responsibilities:
  • Develop and coordinate strategic fact-driven investigative projects, including business process reviews, 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 plans and drive investigative outcomes for the team.
  • Ensure quality outcomes for investigative teams through auditing and oversight.
  • Prioritize, track, and report the status of investigations.
  • Report identified corporate financial impact issues.
  • Utilize 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 approaches.
  • Collaborate with data analytics teams and utilize RAT STATS on Statistically Valid Random Sampling.
  • Coordinate on-site and desk audits of medical record reviews and claim audits.
  • Manage and decide claims pending 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 plans.
  • 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.
  • Develop regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agencies.
  • Manage and maintain sensitive confidential investigative information.
  • 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.
  • Develop and present internal and external formal presentations.
  • Attend fraud, waste, and abuse training/conferences.
  • 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.
Requirements:
  • Bachelor's Degree or equivalent years of relevant work experience in a Health-Related Field, Law Enforcement, or Insurance required.
  • Master's Degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing) preferred.
  • Minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics, or related fields required.
Competencies, Knowledge, and Skills:
  • 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 loads.
  • Ability to develop, prioritize, and accomplish goals.
  • Self-motivated, self-directed.
  • Strong written skills with the ability to compose detailed investigative reports and professional internal and external correspondences.
  • Presentation experience.
  • Knowledge of Medicaid, Medicare, healthcare rules preferred.
  • Background in medical terminology, CPT, HCPCS, ICD codes, or medical billing preferred.
  • Complex project management skills preferred.
  • Display leadership qualities.
Licensure and Certification:
  • Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE), and Certified Professional Coder (CPC) certifications are required.
  • 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.
  • Occasional travel (up to 10%) to attend meetings, training, and conferences may be required.
Compensation Range:

$69,400.00 - $111,000.00 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. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type:

Salary

Competencies:
  • Create an Inclusive Environment
  • Cultivate Partnerships
  • Develop Self and Others
  • Drive Execution
  • Influence Others
  • Pursue Personal Excellence
  • Understand the Business

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