SIU Investigator III (Must live in Arkansas)

CareSource Management Services; Arkansas; Hybride; USD 90 000 - 140 000; Plein temps

Résumé du poste

CareSource Management Services is seeking a Special Investigations Unit III to lead high-complexity healthcare fraud investigations. You will research, analyze data, and develop evidence-based reports, serving as a subject matter expert for investigators.

Responsibilities include coordinating audits, conducting interviews, and driving corrective actions with regulatory and legal teams to resolve fraud, waste, and abuse cases. Strong knowledge of Medicaid/Medicare rules is preferred.

Qualifications

• Bachelor's degree in health-related field or equivalent experience.
• Minimum 5 years in healthcare fraud investigations, medical coding, or related field.
• Experience with data analysis and reporting.
• Knowledge of Medicaid/Medicare rules and CPT/HCPCS/ICD codes preferred.

Responsabilités

• Develop and lead strategic investigative projects with actionable outcomes.
• Validate reports from claims, eligibility, pharmacy and clinical data.
• Coordinate audits of medical records and claim reviews.
• Conduct complex interviews and support formal corrective actions.
• Present findings to Legal and regulatory partners for action.
• Maintain compliance with state and federal laws and corporate policies.

Connaissances

Microsoft Office

Critical thinking

Interpersonal skills

Problem solving

Research

Data analysis

Independent judgment

Leadership

Communication

Formation

Bachelor's degree in health-related field

Master's degree in criminal justice/public health/statistics/health economics/nursing

Description du poste

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 fol