Responsible for triaging, investigating and resolving all assigned allegations of healthcare FWA by medical professionals, facilities, and members. Healthcare FWA examples include, but are not limited to, member identify theft, misappropriation of services, up-coding, services not rendered, unbundling, etc.
All assigned cases require thorough investigation; investigative strategy development; evidence gathering to include medical record review and analysis, trend and pattern identification; chain of custody, and; report writing.
Key responsibilities include conducting member/provider/staff interviews, collecting evidence, preparing case information for civil and/or criminal litigation or prosecution, negotiating settlement or resolution proposals, developing corrective action plans, participating in information sharing sessions and/or Fraud Task Force discussions, creating internal/external summary reports, and recommendations for investigative action.
While this individual will perform some medical record review it will be in conjunction with a Medical Director or cases will be referred to the RN Investigator for the clinical review of a case.
- Conducts investigations on own initiative or at the request of management. Investigation includes data analysis, record review, cross company discussions, clinic inspections, member/provider interviews, coordination with legal representative, and legal case preparation.
- Performs data mining utilizing fraud, waste and abuse detection software to identify aberrancies and outliers.
- Provides updates and reports on investigation cases’ progress and coordinates with SIU team members and management on recommendations, developing investigative plans, further actions and/or resolution.
- Coordinates claim audits by requesting probe and full statistical claim samples utilizing either random or targeted methodologies.
- Works with the RN Investigator to compare medical records to bills submitted for payment looking at documentation compared to ICD-9, CPT, and HCPCS codes.
- Examines abnormal claims and billing trends to determine if they appear to be fraudulent.
- Consults with medical directors and physician experts when necessary.
- Applies subject -matter knowledge to solve common and complex investigations.
- Conducts or participates in on-site audits of medical professionals, business partners and contracted entities.
- Arranges and conducts meetings with providers, provider employees, business partners and where appropriate, representatives from regulatory agencies and law enforcement in the conduction of investigations.
- Creates proposed provider education and corrective action plans.
- Collaborates with other departments including, but not limited to, Pharmacy, Medical Management, Provider Relations, Claims, Finance, Internal Audit, Regulatory, and Legal.
- May act as a team or project leader providing direction for team activities, facilitating information validation and team decision-making processes.
- Responsible for maintaining confidentiality of all sensitive investigative information.
- Develops and maintains contacts/liaison with law enforcement, regulatory agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention.
- Prepares summary and/or detailed reports on investigative findings and/or referrals to state and federal agencies to include, but not limited to, the MEDIC, FBI, Attorney General MFCU, HHS-OIG, MDCH, ODJFS, CMS and local law enforcement.
- Creates, prepares and presents external, formal presentations including, but not limited to, local and national fraud training conferences, law enforcement and other agencies.
- Responsible for departmental educational training on clinical issues, CPT coding and medical updates as determined by collaboration with management.
- Must have ability to attend meetings, training and conferences. Overnight travel may be required.
- Assists in achieving and maintaining compliance with state and federal FWA compliance and other rules and regulations.
- Assist with unit’s efforts to increase fraud and abuse training and awareness to all employees, members, and providers.
- Documentation of internal process or procedure deficiencies based on investigative findings with recommended changes.
- Know and uphold the provisions of the Corporate Compliance Plan.
- Perform any other job related instructions as requested, with reasonable accommodation.
• Proactively uses analytical skills to identify potential areas of FWA or areas of risk to FWA and develop investigative plans for solutions.
• Contacts members, pharmacies, providers and third parties via telephone interview and/or letter to validate claim submissions and clarify allegation of FWA
• Responsible for assisting SIU in meeting all regulatory and departmental deadlines.
• Recommends and participates in development and implementation of internal departmental policies and procedures.
• Associate’s Degree, Bachelors Degree or equivalent work experience in Health-Related Field, Law Enforcement, or Insurance
- 3-5 years experience in medical coding, pharmacy, medical research, auditing, law enforcement, etc.)
• NICB, IASIU, ACFE, HCAFA or NHCAA certificates or training in healthcare fraud and abuse investigations not required but is a plus.
- Intermediate computer skills consisting of Microsoft Excel, Access, Outlook, Word, and Power Point.
- EDI Watch’s Intelligent Investigator Software
- I-Sight Case Management Software
Knowledge & Skills
- Ability to perform research and draw conclusions
• Ability to present issues of concern alleging schemes or scams to commit FWA
• Ability to organize a case file, accurately and thoroughly document all steps taken
• Ability to report work activity on a timely basis
• Ability to work independently and as a member of a team to deliver high quality work.
• Ability to support heavy workload and meet critical regulatory guidelines
• Ability to compose correspondence, and prepare recommendations, reports, and referral summaries.
• Ability to communicate effectively, internally and externally
• Presentation skills necessary
• Knowledge of Medicaid, helpful
• Good knowledge of medical terminology, medical diagnostic, procedural terms, and medical billing
• Works on problems/projects of diverse complexity and scope
• Proficient in Microsoft Office applications to include MS Word, Excel and Outlook.
• Leadership experience and skills
• Ability to attend meetings, training and conferences, overnight travel may be required.
• Critical Listening and Thinking Skills
The statements contained herein describe the essential functions of this position. This description is not an all-inclusive listing of work requirements. Individuals may perform other duties as assigned, subject to reasonable accommodation.
CareSource is a leading non-profit public-sector managed care company based in Dayton, Ohio. CareSource has been meeting the needs of underserved health care consumers for more than 23 years. Since inception, CareSource has grown to be the largest Medicaid managed care plan in Ohio and the 2nd largest in the country.
We provide services through contracts with the Ohio Department of Job and Family Services, and the Center for Medicare and Medicaid Services.