Program Integrity Investigative Coordinator I

Job Summary:

The Program Integrity Investigative Coordinator I monitors and maintains all SIU fraud reporting mechanisms (hotline, facets routing, fax, emails) to ensure compliance with regulatory requirements.

Essential Functions:

• Accurately load Fraud, Waste & Abuse (FWA) referrals into the SIU Case Management System
• Analyze FWA allegation facts and evaluate whether cases can be closed or escalated
• Interview claimants, providers, members or any other individuals to obtain information relevant to any FWA investigation
• Review claims for irregular billing patterns, consulting specialists when necessary
• Generate various reports utilizing multiple fraud detection software systems
• Conduct rudimentary data analysis to determine financial exposure or risk to FWA allegation across all lines of business
• Responsible for maintaining anonymity and confidentiality during all phases of intake process
• Independently identify billing errors and accidental overpayments initiating corrective action through the Research and Resolution Submission portal
• Request medical records on an as-needed basis and as directed by Team Lead; partner with Clinical staff to resolve any issues
• Assist Program Integrity in the oversight of Delegated Entities by routing state directed correspondence and generating claims data reports across all lines of business  
• Prepare and document Attestations, De-conflictions and Additional Allegation FWA informational letters, as contractually required, for any state Medicaid agency
• Attend state Medicaid investigative meetings to transcribe updates provided by the Attorney General’s Office; update any applicable cases
• Support compliance and regulatory requirements by verifying all state/federal directed provider removals are completed accurately across all lines of business
• Drive accuracy of database information maintained in Case Management System; proactively verify the accuracy of provider information in concert with Facets and the Medicaid Information Technology System
• Know and uphold the provisions of the Corporate Compliance Plan
• Perform any other job related instructions as requested

Education and Experience:

• High School Diploma or GED is required
• Associate’s Degree in Health-Related Field, Law Enforcement, or Insurance is preferred
• Minimum of three (3) years’ experience in a health care related field or Customer Service is required
• Health care experience preferred (medical/dental claims, auditing, medical office experience, etc.)

Competencies, Knowledge and Skills:

• Intermediate computer skills consisting of Microsoft Excel, Access, Outlook, Word, and Power Point
• Ability to navigate multiple software systems at a high proficiency level
• Good communication skills
• Ability to work independently and within a team environment
• High attention to detail
• Critical listening and thinking skills
• Proper grammar usage
• Time management skills
• Proper phone etiquette
• Customer service oriented
• Decision making/problem solving skills
• Strong organization skills
• Customer service oriented

Licensure and Certification:

• None

Working Conditions:

• 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

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business