Role and Responsibility: •Responsible for investigating and resolving all assigned allegations of healthcare FWA by medical professional, facilities, and members •Conducts investigations on own initiative or at the request of management. Investigation includes data analysis, record review, cross company discussions, clinic inspections, member/provider interviews, coordination with legal representative, and legal case preparation •Performs data mining utilizing fraud, waste and abuse detection software to identify aberrancies and outliers •Provides updates and reports on investigation cases’ progress and coordinates with SIU team members and management on recommendations, developing investigative plans, further actions and/or resolution •Coordinates claim audits by requesting probe and full statistical claim samples utilizing either random or targeted methodologies •Works with the RN Investigator to compare medical records to bills submitted for payment looking at documentation compared to ICD-9, CPT, and HCPCS codes •Examines abnormal claims and billing trends to determine if they appear to be fraudulent •Consults with medical directors and physician experts when necessary •Applies subject -matter knowledge to solve common and complex investigations •Conducts or participates in on-site audits of medical professionals, business partners and contracted entities •Arranges and conducts meetings with providers, provider employees, business partners and where appropriate, representatives from regulatory agencies and law enforcement in the conduction of investigations •Creates proposed provider education and corrective action plans •Collaborates with other departments including, but not limited to, Pharmacy, Medical Management, Provider Relations, Claims, Finance, Internal Audit, Regulatory, and Legal •May act as a team or project leader providing direction for team activities, facilitating information validation and team decision-making processes •Responsible for maintaining confidentiality of all sensitive investigative information •Develops and maintains contacts/liaison with law enforcement, regulatory agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention •Prepares summary and/or detailed reports on investigative findings and/or referrals to state and federal agencies to include, but not limited to, the MEDIC, FBI, Attorney General MFCU, HHS-OIG, MDCH, ODJFS, CMS and local law enforcement •Creates, prepares and presents external, formal presentations including, but not limited to, local and national fraud training conferences, law enforcement and other agencies •Responsible for departmental educational training on clinical issues, CPT coding and medical updates as determined by collaboration with management •Must have ability to attend meetings, training and conferences. Overnight travel may be required •Assists in achieving and maintaining compliance with state and federal FWA compliance and other rules and regulations •Assist with unit’s efforts to increase fraud and abuse training and awareness to all employees, members, and providers •Documentation of internal process or procedure deficiencies based on investigative findings with recommended changes •Know and uphold the provisions of the Corporate Compliance Plan •Proactively uses analytical skills to identify potential areas of FWA or areas of risk to FWA and develop investigative plans for solutions •Contacts members, pharmacies, providers and third parties via telephone interview and/or letter to validate claim submissions and clarify allegation of FWA •Responsible for assisting SIU in meeting all regulatory and departmental deadlines •Recommends and participates in development and implementation of internal departmental policies and procedures
Perform any other job related instructions, as requested
Education / Experience: •Bachelor’s Degree or equivalent years of relevant work experience in Health-Related Field, Law Enforcement, or Insurance required •Minimum of three (3) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics, or related field is required
Required Competencies / Knowledge / Skills:
•Intermediate computer skills consisting of Microsoft Excel, Access, Outlook, Word, and Power Point. •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 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 / 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 Accountability:
•General office environment; may be required to sit/stand for long periods of time
Occasional travel (up to 10%) to attend meetings, training, and conferences may be required
Join Our CareSource Team
The strength of CareSource lies in our most important asset – our employees. They work each day with compassion and a commitment to improving health care.
Our mission to make a lasting difference in our members’ lives by improving their health and well-being is one we take to heart. It permeates the work we do each day, and it is a cornerstone that supports our corporate culture.
Our employees are people who are proud to be part of a high-energy, people-centered company. Join us and you will find a place where employees:
•Make service to our customers their top priority.
•Put people first by respecting, affirming and valuing each individual.
•Conduct themselves with honesty and integrity by upholding high ethical standards.
•Strive for quality results by continually measuring performance and working toward improvement.
•Use teamwork and open communication, encouraging and valuing the contributions of all to achieve collective goals.
•Have a passion for learning and encourage individual and team skill development.