Program Integrity Controls Analyst II (Compliance Experience required)

Job Summary:

The Program Integrity (PI) Controls Analyst II is responsible for compliance and oversight of fraud, waste, abuse, Program Integrity-related requirements, and for management of our fraud risk framework  for all product lines in all states to ensure delivery on commitments.

Essential Functions:

• Support SIU implementation of Program Integrity Medicaid/Medicare/Marketplace legal, regulatory and contract requirements
• Provide quality assurance monitoring for all  PI required state and federal monthly, quarterly, ad hoc and annual reports
• Work with PI functional areas to develop risk mitigation strategies and change implementation plans based on risk assessment processes
• Ability to attend conferences, outreach to organizations such as the Health Care Compliance Association (HCCA), other managed care plans to identify best in industry PI practices
• Monitor program integrity solutions put in place for ongoing compliance and for continuous improvement opportunities
• Support the development, evaluation and revision of FWA detection, deterrent and prevention policies and procedures/processes; ensure compliance with all state and federal requirements
• Support  drafting of responses to all required state and federal audits, questionnaires, surveys and other inquires
• Support  drafting of responses to state and federal Readiness Review Tools (RRTs) and Requests for Proposals
• Collaborate interdepartmentally to develop and implement PI cross-functional policies, procedures and process flows
• Assist with the development of the Program Integrity risk assessment and work plan
• Work on implementation of new compliance/legal requirements
• Represent SIU on key external and internal committees
• Assist in training SIU department personnel on SIU policies, procedures and processes and implementation status
• Write and present reports and participate in department level projects
• Attend any training required by state and federal agencies about Program Integrity compliance
• Initiate and maintain network and outreach activities to ensure best practices in SIU functions
• Prepare, update and/or contribute to all FWA prevention and reporting materials including Provider Manuals, Member Handbooks, Employee Handbook, Member/Provider Newsletters, website pages, check flyers, reporting forms, FWA E-Learning, FWA reporting mechanisms, FWA Policies and Procedures ,etc.
• Support vendor/delegate oversight and monitoring for compliance of PI-related functions
• Create and maintain detail, audit-ready, and product specific documentation for all FWA requirements
• Attend FWA and/or compliance seminars annually to stay current on Program Integrity issues/ emerging risks
• Establish and maintain collaborative working relationships with state, federal and other managed care Medicaid/Medicare/Marketplace Program Integrity functions
• Support NCQA and URAC Program Integrity accreditation initiatives to include any policy, procedure and process changes required and educating SIU staff on requirements
• Know and uphold the provision of the Corporate Compliance Plan
• Maintain confidentiality of all SIU investigative case information
• Monitor PI inbox for incoming inquiries and ensure timely, accurate responses
• Provides cross-training of team members
• Perform any other job-related instructions as requested

Education and Experience:

• Bachelor’s Degree in Compliance, Healthcare or a Legal field or equivalent years of relevant work experience is required
• Minimum of two (2) years of experience in a compliance or legal field is required
• Previous experience in internal and external auditing, risk management and performance improvement are preferred
• Experience with  Marketplace, Medicaid and/or Medicare products is strongly preferred

Competencies, Knowledge and Skills:

• Solid  level of proficiency with Microsoft Office Suite
• Solid data analytics and reporting capabilities
• Strong written and oral presentation skills
• High level of integrity and ethics
• High level communication skills both verbal and written
• Ability to work independently and collaboratively within a team environment
• Understanding of control framework(s) used to manage an effective PI plan and PI vendor/delegate oversight
• High attention to detail
• Familiarity with the healthcare field
• Critical listening and thinking skills
• Skill in negotiating issues and resolving problems
• Strong decision making/problem solving ability
• Ability to manage multiple projects and deadlines

Licensure and Certification:

• Fraud or Compliance designation/certification is preferred

Working Conditions:

• Most work will be performed in an office or virtual setting; however, performing onsite audits may also be necessary depending on assignments
• General office environment; may be required to sit or stand for extended periods of time

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

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business