SIU Investigator I (Hybrid) at CareSource

Job Summary:The Special Investigations Unit (SIU) Investigator I is responsible for comprehensive review, examination, and analysis of assigned allegations of healthcare fraud, waste and abuse (FWA) by medical professionals, facilities, and members. Specific responsibilities may fluctuate to align with department priorities and may include any of the following essential functions.Essential Functions:Support other departments to obtain information needed to support SIU investigative effortsProactively use analytical skills to identify potential areas of FWA or areas of risk to FWAProvide case review progress and coordinate with SIU team members and management on recommendations for further actions and/or resolutionRecommend and participate in development and implementation of internal SIU policies and proceduresAssist in achieving and maintaining compliance with state and federal FWA compliance and other deadlines related to rules and regulationsAssist with unit's efforts to increase fraud and abuse training and awareness to all employees, members, and providersResponsible for maintaining confidentiality of all sensitive investigative informationKnow and uphold the provisions of the Corporate Compliance PlanPerform any other job-related instructions as requestedInvestigative Case TriageTriage, examine, and analyze all assigned allegations of healthcare fraud, waste and abuse by medical professionals, facilities, and membersConduct assigned case triage with high level of autonomy and include data analysis, record review, cross-company discussions, member/provider interviews, and member/provider educationUse concepts and knowledge of CPT, ICD, HCPCS, DRG, REV coding rules to analyze provider claim submissionsContact members, pharmacies, providers and third parties via telephone interview and/or letter to validate claim submissions and clarify allegation of FWAPerform data mining utilizing FWA detection software to identify aberrancies and outliersResearch, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules, and guidelinesCollaborate with investigative team on appropriate support initiatives from triage activitiesInvestigative Case SupportProvide support of delegative vendor investigationsMonitor SIU issued Corrective Action Plans, Settlement Agreements, and RestitutionsEnsure that credible allegations of fraud and state suspensions are actioned appropriately across the organizationGenerate SIU metrics as requiredEnsure compliance and documentation to support regulatory requirementsGenerate and analyze data to support cases on stand-down, prepay, or AUDP and document financials in the caseSubmit deconfliction and permission requests to our market partners to ensure regulatory compliance and investigative efficiencySupport triaging and managing the fraud reporting mechanisms, including case input into SIU case tracking softwareSupport investigators in case development such as records requests/reviews, letter generation, and documentationBroker Case Support:Review allegations of inappropriate enrollment by brokers and coordinate with matrix partners to investigate and resolve these allegationsTriage these cases, as appropriate, to the SIU for full investigationWaiver Case Support:Review of all Incident Management System (IMS) documents and other tips received through CareSource fraud reporting mechanisms to determine if the allegation requires further review.Responsible for referring suspected fraud to market regulators and presenting facts of the referral and initiating claims adjustments, when appropriate.Education and Experience:Associates Degree or equivalent years of relevant work experience in a healthcare-related field, law enforcement, or insurance is requiredMinimum of eighteen (18) months experience in medical coding, billing, auditing, data analytics, or related field is requiredCompetencies, Knowledge, and Skills:Intermediate computer skills consisting of Microsoft Excel, Access, Outlook, Word, and Power Point.Ability to present issues of concern alleging schemes or scams to commit FWAAbility to work independently and as a member of a team to deliver high quality workAbility to support heavy workload and meet critical regulatory guidelinesStrong attention to detailEffective communication skills both written and verballyKnowledge of Medicaid and Medicare preferredStrong knowledge of medical terminology, medical diagnostic, procedural terms, and medical billingEffective Listening and Thinking SkillsLicensure and Certification:Certified Fraud Examiner (CFE) or Anti-Healthcare Fraud Investigator (AHFI) certification is preferred. If not currently certified, this certification should be attained within 1 year of hire date.NHCAA or other fraud and abuse investigation training is preferredWorking Conditions:General office environment; may be required to sit or stand for extended periods of timeCompensation Range:$53,400.00 - $85,600.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.Compensation Type:SalaryCompetencies:- Fostering a Collaborative Workplace Culture- Cultivate Partnerships- Develop Self and Others- Drive Execution- Influence Others- Pursue Personal Excellence- Understand the BusinessThis job description is not all inclusive. CareSource reserves the right to amend this job description at any time. 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