Program Integrity Investigator IV

Job Summary:

The Program Integrity Investigator IV / FWA Lead Generator conducts 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 and develop metrics around transactional and operational data to report on fraud attempts, losses and trends.

Essential Functions:

• Identify trends and patterns using standard corporate, processes, tools, reports and databases as well as leveraging other processes and data sources
• Generate graphics that effectively describe, explore and summarize analysis for communication to appropriate parties
• Monitoring of and providing explanation of anomalies related to trends associated with the potential for Fraud Waste and Abuse across the corporate enterprise
• Perform data analyses in support of both the SIU Program Integrity and Audit Functions
• Monitors emerging internal and external FWAE data vulnerabilities and trends which may impact CareSource and create solutions to mitigate risk
• Identify trends and patterns using standard corporate, processes, tools, reports, and databases as well as leveraging other processes and data sources
• Research policies, coding guidelines, and regulations that would support the hypothesis being developed
• Review reports and data for pattern identification, special cause variation identification, trend analysis, or other techniques that will reveal intelligence for identification of any associative or causal relationships pertaining to Fraud Waste and Abuse and Error, providing management level summaries that explain key findings and providing documentation for use during Audits
• Collaborate with the Legal Department, generating data and analyses to support Legal proceedings
• Utilize statistical analysis programming skills to detect patterns of potential fraud in large healthcare data sets.
• Trend data to identify potential opportunities (e.g., variances, significant outliers, percentile ranked groups) for quality improvement or focused investigations
• Aid in design data analysis strategies to identify potential areas for quality improvement or focused investigation
• Facilitate design re-measurement strategies (after intervention) of healthcare processes and outcomes to effectively quantify impact of interventions for improvement
• Develop metrics around transactional and operational data to report on fraud attempts, losses and trends
• 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
• Predict and detect emerging health care fraud trends and develop innovative technological solutions to identify them
• 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 or Healthcare data analysis required
• Health care delivery and/or payer experience required
• Previous Law Enforcement experience preferred

Competencies, Knowledge and Skills:

• Proven analytic skills in solving multi-dimensional problems
• Advanced level experience in Microsoft Applications:  Excel, Access, Word and PowerPoint
• SAS and SQL skills and experience for analytics projects, including database queries
• OIG/ FBI/MFCU knowledge and experience
• Graphic development/presentation skills
• 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 Medicaid, Medicare and managed care
• 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:

• Certified Fraud Examiner or Accredited Healthcare Fraud Investigator preferred
• Coding certification through AAPC or AHIMA preferred

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