TENNCARE FRAUD INVESTIGATOR - 67295

State of Tennessee; Nashville (TN); Hybrid; USD 60,000 - 80,000; Full time

Job summary

An established industry player is seeking a dedicated TennCare Fraud Investigator to join their team in Nashville. This role focuses on combating Medicaid fraud, waste, and abuse through thorough investigations and audits. The ideal candidate will possess a strong background in health-related fields or criminal justice, with a keen eye for detail and excellent analytical skills. In this hybrid position, you'll enjoy a blend of remote and in-office work, contributing to meaningful initiatives that impact the lives of Tennesseans. Join a collaborative environment where your expertise will help enhance the quality of care within the community.

Qualifications

• Bachelor's degree or 3 years of clinical experience required.
• Experience with Medicaid and medical claims processing preferred.

Responsibilities

• Assist with administrative actions and overpayments.
• Coordinate meetings and review reports for investigations.

Skills

Analytical Skills

Researching Medical Policies

Communication Skills

Detail-oriented

Critical Thinking

Education

Bachelor's Degree in Health-related Field

Bachelor's Degree in Criminal Justice

Certifications (AHFI, CPC, CCS, RN, CFE)

Tools

RAT-STATS

SAS

Pallium

Job description

Executive Service

TENNCARE FRAUD INVESTIGATOR

Division of TennCare
Managed Care Operations (MCO)
Nashville, TN

Minimum Monthly Salary: $5,050/month. TennCare compensation is equitable and will be based on education and experience for a qualified candidate in accordance with Department of Human Resources (DOHR) policy.

Closing Date: 05/12/2025

The Division of TennCare is dedicated to providing our employees with a hybrid work environment. All TennCare positions have a combination of work from home and work in the office, which varies by position, department, and business need. You may review the specific expectations with our hiring team.

Background Check: This position requires a background check. Therefore, you may be required to provide information about your criminal history in order to be considered for this position.

Who we are and what we do:

TennCare is Tennessee's managed care Medicaid program that provides health insurance coverage to certain groups of low-income individuals such as pregnant women, children, caretaker relatives of young children, older adults, and adults with physical disabilities. TennCare provides coverage for approximately 1.7 million Tennesseans and operates with an annual budget of approximately $14 billion. It is run by the Division of TennCare with oversight and some funding from the Centers for Medicare and Medicaid Services (CMS). TennCare's mission is to improve the lives of Tennesseans by providing high-quality, cost-effective care. We empower employees and foster collaboration to improve organizational processes, making a difference in our members' lives. TennCare employees find their work meaningful, purposeful, and fulfilling. Leadership prioritizes professional and leadership development.

Job Overview:

Medicaid fraud, waste, and abuse is a priority for CMS. To meet CMS requirements, OPI has created a Regulatory Unit to handle provider suspensions, terminations, recoupments, settlements, and manage deliverables related to CMS Provider Exception List, 42 CFR Part 455 Subpart B Attestations, Conflict of Interest, Prohibition of Illegal Immigrants, and Ownership and Financial Disclosure Reports. The position reports to the Regulatory Manager.

Key Responsibilities:

• Assist the Manager with administrative actions and overpayments.
• Assist with surveys, audits, and annual business requirements.
• Coordinate UPIC meetings and review reports for investigations.
• Review MCC documents submitted to the Tennessee Department of Commerce and Insurance for accuracy regarding FWA.
• Reconcile settlement spreadsheets from TBI, AG, and Fiscal.
• Update settlements in Pallium, OPI's case management software.
• Review deliverables from Managed Care Partners.
• Verify terminated providers for outside entities.
• Assist with special projects as needed.

Minimum Qualifications:

Bachelor's Degree in a health-related field or Criminal Justice, or at least 3 years of related clinical experience; experience researching medical policies, rules, and regulations; general knowledge of medical/dental claims processing; certifications such as AHFI, CPC, CCS, RN, or CFE; intermediate skills with analytical software like RAT-STATS, SAS; working knowledge of Medicaid, preferably TennCare's program.

Alternatively, an equivalent combination of education and work experience may be considered.

Desirable Qualifications:

• Bachelor's Degree or higher in Healthcare or Criminal Justice preferred.
• Certified Professional Compliance Officer (CPCO).
• Detail-oriented, highly organized, active listener, critical thinker.
• Ability to identify needs and suggest solutions, adapt to changing priorities, foster relationships, and communicate effectively.
• Working knowledge of Medicaid and TennCare's program.

In accordance with the State of Tennessee's Workplace Discrimination and Harassment policy, the State is committed to fair and equal employment opportunities and strives to provide an environment free of discrimination and harassment based on race, color, national origin, age, sex, pregnancy, religion, creed, disability, veteran's status, or other protected categories.