SIU Investigator III (Must live in Arkansas)

CareSource; Arkansas; Sur place; USD 65 000 - 104 000; Plein temps

Résumé du poste

CareSource is seeking an SIU III to lead complex investigations into healthcare fraud, waste and abuse. The role involves researching provider billing patterns, analyzing claims and clinical data, and coordinating with analytics to produce actionable outcomes.

Requires at least five years in healthcare fraud and a bachelor’s degree in a health-related field. The candidate will supervise investigative plans, conduct interviews, and liaise with regulators and legal teams.

Qualifications

• Bachelor’s Degree or equivalent years of relevant work experience in health-related field, law enforcement, or insurance.
• Master’s Degree preferred in criminal justice, public health, mathematics, statistics, health economics, nursing.
• Minimum of five years in healthcare fraud investigations or related fields.

Responsabilités

• Develop, coordinate and conduct strategic fact-driven investigative projects.
• Manage reports from detailed claims, eligibility, pharmacy and clinical data.
• Oversee investigative plans and outcomes for the team.
• Audit and ensure quality outcomes for the investigative function.
• Research and interpret Medicaid, Medicare, and ACA regulations.
• Collaborate with data analytics and apply sampling techniques.

Connaissances

Healthcare fraud investigations

Data analysis

Medical coding knowledge

Microsoft Office

Interviewing

Formation

Bachelor’s Degree or equivalent in health-related field

Master’s Degree preferred

AHFI/CFE/CPC preferred

Outils

RAT STATS

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. Must reside in Arkansas.

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

$64,980.00 - $103,950.00

Compensation Type (hourly/salary)

Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business

Equal Opportunity Employer

CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-SD1 Brand=CareSource

Company Mission

The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference‑makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer‑centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.