Job Summary:

The Special Investigations Unit (SIU) Investigator Lead is the face of the SIU with external federal and state regulatory agencies and is responsible for regulatory communications to ensure timeliness with these oversight agencies. This role is also responsible for the identification and monitoring of emerging FWA trends and conducting research and interactions on claims, industry and other sources (internal and external) of data and information to identify potential FWA and support ongoing fraud investigations. Utilizes a variety of data analytics platforms to mine large volumes of data to identify and mitigate fraudulent claim activity, discover patterns and anomalies in billing behavior.

Essential Functions:

• Identify risks and guard against fraud, waste, and abuse by interacting with internal and external business partners through development and monitoring of the Annual Program Integrity Fraud, Waste and Abuse Plan
• Develop and implement innovative best practices to align with future growth and ongoing regulatory oversight
• Act as the Program Integrity liaison and ensure collaboration with state and federal agencies and facilitate accurate deployment and ongoing monitoring of state-specific regulations and ongoing partnership with state regulators in managing Medicaid and Medicare programs
• Engage in external fraud associations, forming relationships with industry leads, (i.e. other MCEs, NHCAA, etc.)
• Predict emerging fraud, waste and abuse trends and communicate strategy to monitor and identify risk to CareSource
• Identify opportunities for cost avoidance through prepayment review, provider education, or other preventative measures
• Responsible for regulatory reporting accuracy and other ad hoc regulatory inquiries
• Ensure that the team is submitting a consistent high volume of quality FWA referrals to our state partners
• Lead investigation on-sites and serve as a mentor for the team
• Conduct and assist investigators with complex investigations
• Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling
• Manage case turn-around times to promote efficiency in investigations and to mitigate risk to CareSource
• Meet quality standards of case documentation
• Generate leads in our fraud detection system to result in investigations that will prevent risk to CareSource. Trend data to identify potential opportunities (e.g., variances, significant outliers, percentile ranked groups) for quality improvement or focused investigations
• Identify trends and patterns using standard corporate processes, tools, reports, and databases, as well as leveraging other processes and data sources such as policies, coding guidelines, and regulations that would support the hypothesis being developed
• 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
• Aid in design data analysis strategies to identify potential areas for quality improvement or focused investigation
• Monitor various media, state and federal press releases to identify emerging schemes and any potential impact and/or exposure
• Lead and participate in all information sharing activities and produce actionable data analyses from information obtained
• 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 Fraud & Abuse Investigations required
• Master’s Degree (e.g., Criminal Justice, public health, mathematics, statistics, experimental psychology, epidemiology, health economics, nursing) preferred
• Minimum of 10 (ten) years of experience in Healthcare Fraud, Healthcare data analysis, or Compliance required
• Previous Law Enforcement experience preferred

Competencies, Knowledge and Skills:

• Proven analytic skills in solving multi-dimensional problems
• Advanced level experience in Microsoft Applications, including Excel, Access, Word and PowerPoint
• SAS and SQL skills and experience for analytics projects, including database queries preferred
• OIG/ FBI/MFCU knowledge and experience
• Knowledge of inferential statistics
• Working knowledge of descriptive statistical application and techniques
• Critical listening, thinking skills, and verbal and written communication skills
• Decision making/problem solving skills
• Ability to work independently and within a team environment
• Knowledge of multiple Medicaid, Medicare and managed care plans
• Strong Knowledge of inpatient and outpatient coding standards, billing rules and regulations and knowledge of procedure and diagnosis codes (CPT, ICD10 coding, HCPCS, APC and DRGs)
• Knowledge of value-based reimbursement methodology
• Ability to lead analytic efforts
• Customer Service Oriented

Licensure and Certification:

• Two of the following are required: Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Certified Professional Coder (CPC) or 6 years of coding experience

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:

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 (hourly/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

This 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.