Program Integrity Analyst

SoftDev Incorporated; Pennsylvania; On-site; USD 70,000 - 100,000; Full time

Job summary

SoftDev Incorporated is seeking a Program Integrity Analyst to join our CMS-related team. The role involves high level investigations of medical service providers, case development for referrals, and collaboration with state and federal partners to address fraud, waste, and abuse.

The investigator will handle multiple caseloads, prepare reports, and maintain health privacy compliance while supporting data requests and corrective actions across multiple jurisdictions.

Qualifications

• US Citizen or Green Cardholder.
• BS 5-7 Years, MS 3-5, PhD 0-2
• Three to five years investigative experience preferred
• Strong investigative skills
• Strong communication and organization skills
• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
• Strong PC knowledge and skills
• Must pass a drug screening
• Must pass a criminal background check
• Must reside in any of the following states: Florida, Georgia, Alabama, Tennessee, South Carolina, North Carolina, Virginia, or West Virginia

Responsibilities

• This position will perform high level complex investigations of medical professional service providers and develop cases for future action, including referral to law enforcement, education, over payment recovery and other administrative actions.
• Will work with internal resources and external agencies to develop cases and corrective actions as well as respond to requests for data and support.
• Investigators may need to prepare complex investigative reports that apply regulations or rules to the programs affected by the behavior being investigated.
• Investigators will need to apply federal or state laws and maintain confidentiality of health privacy information.

Skills

Investigative skills

Data analysis

Communication skills

Team collaboration

Education

BS in a relevant field

MS preferred

PhD optional

Tools

MS Office

Data systems

Job description

SoftDev is seeking a qualified candidate to serve as a Program Integrity Analyst to join our team! SoftDev is performing Medicare and Medicaid Program Integrity work for the Centers for Medicare & Medicaid Services (CMS). The overall project includes data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse.

Position Overview

The position is expected to perform high level complex investigations of medical professional service providers and develop cases for future action, including referral to law enforcement, education, over payment recovery and other administrative actions. Will work with internal resources and external agencies to develop cases and corrective actions as well as respond to requests for data and support. This position will work with the Southeast Unified Program Integrity Contractor which supports the following states: Florida, Georgia, Alabama, Tennessee, South Carolina, North Carolina, Virginia, West Virginia, and the territories of Puerto Rico and the US Virgin Islands.

An investigator uses good judgment and may work independently with minimum supervision and direction. The investigator also may work as part of a team as there may be times when the investigator needs to work with state and/or federal investigators and other personnel. An investigator handles multiple caseload assignments concurrently; organizes and analyzes complex evidentiary patterns; interviews and obtains statements from witnesses and others.

Investigators may also be required to complete complex investigative reports that apply regulations or rules to the program(s) affected by the behavior being investigated. There may also be times when the investigator will need to apply federal or state laws.

Investigators are expected to research and understand the relevant offenses being investigated; conduct efficient and effective investigations concerning those alleged offenses and detect or verify suspected violations; obtain information and evidence by observation, record examination, and interview. Investigators then analyze the results of the investigation to ascertain if the allegations have been corroborated and work with others to determine the appropriate steps that need to be taken to address the issues.

As part of an investigation, the investigator will need to prepare correspondence; be objective and accurate and communicate with others with tact. There may be times when investigators need to react to unplanned situations, be flexible in planning their activities and adopt effective courses of action.

As investigators will be working with health privacy information, they also must maintain confidentiality and understand all the laws, rules and regulations concerning health privacy.

Prerequisites

• US Citizen or Green Cardholder
• BS 5-7 Years, MS 3-5, PhD 0-2
• Three to five years investigative experience preferred
• Strong investigative skills
• Strong communication and organization skills
• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
• Strong PC knowledge and skills
• Must pass a drug screening
• Must pass a criminal background check
• Must reside in any of the following states: Florida, Georgia, Alabama, Tennessee, South Carolina, North Carolina, Virginia, or West Virginia

Desirable Qualifications - The most competitive candidates will have:

• Strong background in investigations
• Knowledge of investigative practices regarding healthcare providers
• Knowledge of Medicare and/or Medicaid programs and the rules, regulations, policies and procedures
• Background in evaluating, reviewing and analyzing medical claims and records
• Ability to learn and operate a variety of data systems, equipment and tools used in investigations

Essential Functions

• This position may require the incumbent to appear in court to testify about work findings
• Ability to perform research and draw conclusions
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
• Ability to organize a case file, accurately and thoroughly document all steps taken
• Ability to compose correspondence, reports and referral summary letters
• Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters
• Ability to communicate effectively, internally and externally
• Ability to interpret laws and regulations
• Ability to handle confidential material
• 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 attend meetings, training, and conferences, overnight travel required

SoftDev is strongly committed to the policies and principles of Equal Employment Opportunity (EEO), Employment decisions and practices, including but not limited to recruitment, selection, job assignment, transfer, promotion, discipline, training, compensation and benefits will be made without regard to race, color, religious creed, national origin, sex, citizenship, genetic information, marital status, age, sexual orientation, disability and/or US Veteran status, in accordance with applicable Federal, State, and Local laws. SoftDev is an Equal Opportunity / Affirma