Job Description

Job Summary:

The Special Investigations Unit (SIU) III is responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professional, facilities, and members. Researches, gathers, and analyzes data to identify trends, patterns, aberrancies, and outliers in provider billing behavior. Serves as a subject matter expert for other investigators.

Essential Functions:

• Develop, coordinate and conduct strategic fact-driven investigative projects including business process review, 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 plan and drive investigative outcome for the team
• Ensure quality outcomes for investigative team through auditing and oversight
• Prioritize, track, and report status of investigations
• Report identified corporate financial impact issues
• Use 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 approach
• Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling
• Coordinate and conduct on-site and desk audits of medical record reviews and claim audits
• Manage and decision claims pended 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 plan
• 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
• 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
• SME in the designated market and ability to apply external intelligence to their analysis and case development
• Develop and present internal and external formal presentations, as needed 
• Attend fraud, waste, and abuse training/conferences, as needed
• Support regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agencies
• Manage and maintain sensitive confidential investigative information
• 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
• Perform any other job-related instructions, as requested

Education and Experience:

• Bachelor’s Degree or equivalent years of relevant work experience in 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 field is 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 load
• Ability to develop, prioritize and accomplish goals
• Self-motivated, self-directed
• Strong written skills with ability to compose detailed investigative reports and professional internal and external correspondences
• Presentation experience, beneficial
• 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:

• One of the following certifications is required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)
• 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

Compensation Range:
$70,800.00 - $113,200.00 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:
- Create an Inclusive Environment - 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 inclusive environment that welcomes and supports individuals of all backgrounds.

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