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Healthcare Fraud Investigator

2 months ago

Little Rock, Arkansas, United States CareSource Full time
Job Summary:

The Healthcare Fraud Investigator is responsible for conducting thorough investigations and resolving allegations of healthcare fraud, waste, and abuse. This role requires analyzing data, reviewing records, and collaborating with internal and external partners to ensure optimal resolution.

Key Responsibilities:
  • Conduct investigations on assigned cases, including data analysis, record review, and cross-functional discussions.
  • Analyze and monitor complaints and incidents, and conduct investigations as necessary.
  • Collaborate with the Special Investigations Unit (SIU) team and management to develop investigative plans and recommendations.
  • Coordinate claim audits and provide updates on investigation cases' progress.
  • Consult with medical directors and physician experts as needed.
  • Apply subject-matter knowledge to solve complex investigations and develop action plans.
  • Conduct on-site audits of medical professionals, business partners, and contracted entities.
  • Collaborate with other departments, including Pharmacy, Medical Management, Provider Relations, Claims, Finance, Internal Audit, Regulatory, and Legal.
  • May act as a team or project leader, providing direction and facilitating information validation and team decision-making processes.
  • Responsible for maintaining confidentiality of sensitive investigative information.
  • Develop and maintain contacts with law enforcement, regulatory agencies, and external contacts involved in fraud investigation, detection, and prevention.
  • Assist with the preparation of cases for grievance and appeals committees' review.
  • Analyze submitted complaints and determine appropriate category, i.e., grievances, appeals, and/or quality of care issues, and monitor for resolution.
  • Investigate and develop action plans on matters related to standards in areas of misconduct/incidents/adverse events, including coordination of internal investigations and any resulting corrective action with all departments.
  • Know and uphold the provisions of the Corporate Compliance Plan.
  • Responsible for assisting SIU in meeting all regulatory and departmental deadlines.
  • Collect and route all Incident Reports and information needed to fill out the DHS required forms and submit to DHS within required timeframes, as well as routing to appropriate CareSource staff.
  • Document Incidents according to CS Policy and timeframes.
  • Coordinate and lead reporting in areas of Quality/Incident Reporting for yearly program evaluation and as needed to meet state requirements.
Requirements:
  • Bachelor's Degree or equivalent years of relevant work experience in a Health-Related Field, Law Enforcement, or Insurance.
  • Minimum of three (3) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics, healthcare operations, or related field.
Competencies, Knowledge, and Skills:
  • Intermediate computer skills consisting of Microsoft Excel, Access, Outlook, Word, and PowerPoint.
  • Experience with EDI Watch's Intelligent Investigator Software and I-Sight Case Management Software.
  • Ability to perform research and draw conclusions.
  • Ability to present issues of concern alleging schemes or scams to commit FWA.
  • Ability to organize a case file, accurately and thoroughly document all steps taken.
  • Ability to report work activity on a timely basis.
  • Ability to work independently and as a member of a team to deliver high-quality work.
  • Ability to support a heavy workload and meet critical regulatory guidelines.
  • Ability to compose correspondence, and prepare recommendations, reports, and referral summaries.
  • Ability to communicate effectively, internally and externally.
  • Presentation skills necessary.
  • Knowledge of Medicaid preferred.
  • Good knowledge of medical terminology, medical diagnostic, procedural terms, and medical billing.
  • Critical Listening and Thinking Skills.
  • Works on problems/projects of diverse complexity and scope.
Licensure and Certification:
  • Certified Fraud Examiner (CFE) or Anti-Healthcare Fraud Investigator (AHFI) is preferred.
  • Certified Professional Coder (CPC) is preferred.
  • 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.