Program Integrity Investigator

Southeastrans, Inc.; Indianapolis (IN); On-site; USD 55,000 - 75,000; Full time

Job summary

Southeastrans, Inc. seeks a Program Integrity Specialist to lead audits of processed claims and help prevent fraud, waste, and abuse. The role focuses on validating payment accuracy and investigating anomalies as the primary resource for audit activities.

The position requires understanding health plan operations and state contract basics, with strong analytical and communication skills to coordinate across departments and document findings.

Qualifications

• Strong analytical, qualitative, and problem-solving skills with the ability to perform root cause analysis and implement workable solutions.
• Ability to multi-task, establish priorities and work independently to achieve objectives.
• Ability to function effectively under pressure.
• Adaptable and flexible while possessing the aptitude to grasp new concepts and assignments quickly.
• Excellent Customer service skills with the ability to interact professionally and effectively with providers and staff from all departments.
• Strong interpersonal skills with the desire and capacity to work in a fast-paced environment whether as a team member or as an independent contributor.

Responsibilities

• Conduct audits and review claims. Documents findings and recommendations.
• Request all information from internal or outside sources to ascertain the completeness and validity of claims.
• Research claims as needed.
• Identifies fraud in any aspect of the organization and services provided. This includes, but is not limited to: Employee fraud, Provider fraud, Member fraud – eligibility, geographic access, member and facility signatures, Public Transportation, Mileage Reimbursement, Volunteer Driver and Internal fraud detection.
• Document work performed and audit results based on pre-determined standards and guidelines.
• Compile case file documentation and issue findings in accordance with applicable policies and procedures; develop, maintain, and manage cases in the internal case tracking system.
• Create and analyze trended reports for the purpose of identifying opportunities for improvement, assessing the effectiveness of such improvements, and sharing of best practices. Examples include no-shows, frequent demand responses, trip verification, Public Transit trends, etc.
• Exercise independent judgment and discretion in using available resources to identify relevant evidence supporting investigations.
• Prepare internal reports.
• Coordination with other departments as needed.
• Basic knowledge of all State contracts.
• Other duties as assigned

Skills

Analytical skills

Problem-solving

Multitasking

Communication

Interpersonal skills

Work under pressure

Education

Bachelor's degree

Investigative experience (2+ years)

Tools

Microsoft Office

Job description

Southeastrans, Inc. seeks a Program Integrity Specialist to lead audits of processed claims and help prevent fraud, waste, and abuse. The role focuses on validating payment accuracy and investigating anomalies as the primary resource for audit activities.

The position requires understanding health plan operations and state contract basics, with strong analytical and communication skills to coordinate across departments and document findings.