Job Title

Reference #: R12273-2Job 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. This is a high case load volume, fast paced environment.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 PlanDevelop and implement innovative best practices to align with future growth and ongoing regulatory oversightAct 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 programsEngage 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 CareSourceIdentify opportunities for cost avoidance through prepayment review, provider education, or other preventative measuresResponsible for regulatory reporting accuracy and other ad hoc regulatory inquiriesEnsure that the team is submitting a consistent high volume of quality FWA referrals to our state partnersLead investigation on-sites and serve as a mentor for the teamConduct and assist investigators with complex investigationsCollaborate with data analytics team and utilize RAT STATS on Statistically Valid Random SamplingManage case turn-around times to promote efficiency in investigations and to mitigate risk to CareSourceMeet quality standards of case documentationGenerate 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 investigationsIdentify 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 developedManage and decision claims pended for investigative purposesMaintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty typesPrepare and conduct in-depth complex interviews relevant to investigative planExecute and manage provider formal corrective action plansParticipate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case developmentParticipate 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 litigationAid in design data analysis strategies to identify potential areas for quality improvement or focused investigationMonitor various media, state and federal press releases to identify emerging schemes and any potential impact and/or exposureLead and participate in all information sharing activities and produce actionable data analyses from information obtainedManage and maintain sensitive confidential investigative informationM intain compliance with state and federal laws and regulations and contractsAdhere to the CareSource Corporate Compliance Plan and the Anti-Fraud PlanAssist in Federal and State regulatory audits, as neededPerform any other job-related instructions, as requestedEducation and Experience:Bachelor's Degree or equivalent years of relevant work experience in Fraud & Abuse Investigations requiredMaster's Degree (e.g., Criminal Justice, public health, mathematics, statistics, experimental psychology, epidemiology, health economics, nursing) preferredMinimum of 10 (ten) years of experience in Healthcare Fraud, Healthcare data analysis, or Compliance requiredPrevious Law Enforcement experience preferredCompetencies, Knowledge and Skills:Proven analytic skills in solving multi-dimensional problemsAdvanced level experience in Microsoft Applications, including Excel, Access, Word and PowerPointSAS and SQL skills and experience for analytics projects, including database queries preferredOIG/ FBI/MFCU knowledge and experienceKnowledge of inferential statisticsWorking knowledge of descriptive statistical application and techniquesCritical listening, thinking skills, and verbal and written communication skillsDecision making/problem solving skillsAbility to work independently and within a team environmentKnowledge of multiple Medicaid, Medicare and managed care plansStrong 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 methodologyAbility to lead analytic effortsCustomer Service OrientedLicensure 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 experienceWorking Conditions:General office environment; may be required to sit or stand for extended periods of timeOccasional travel (up to 10%) to attend meetings, training, and conferences may be requiredCompensation Range:$83,000.00 - $132,800.00 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 pensation Type:SalaryCompetencies:- Fostering a Collaborative Workplace Culture- Cultivate Partnerships- Develop Self and Others- Drive Execution- Influence Others- Pursue Personal Excellence- Understand the BusinessThis 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.#LI-SD1CareSource is an equal opportunity employer and gives consideration for employment to qualified applicants without regard to race, color, religion, sex, age, national origin, disability, sexual orientation, gender identity, genetic information, protected veteran status or any other characteristic protected by applicab