Program Integrity Special Investigative Unit Clinical Investigator

Job Locations US-NC-Gastonia
Posted Date 3 weeks ago(2/1/2018 6:08 PM)
Job ID
# of Openings
Community and Social Services


Excellent Benefits Package!!!

Location: Gastonia

Projected Hiring Range:  $53,964 – $56,805


Closing Date: Open Until Filled


Primary Purpose of Position: This position will assist in the development, implementation, revision, maintenance, and promotion of the agency’s fraud, waste, and abuse prevention and detection activities to ensure that the agency and the agency’s network operates in a manner that follows applicable State and Federal laws and regulations, agency policies, national accreditation, and Medicaid guidelines. This position will perform functions relating to data analysis, investigations, and auditing relating to the monitoring, detection, and resolution of healthcare fraud, waste, and abuse.



Role and Responsibilities:

  • Investigate allegations of suspected regulatory compliance violations, including; fraud, waste, and abuse. Investigative methods include the review of financial, consumer/clinical, provider, and/or other records, reports, and information necessary to thoroughly investigate suspected violations.
  • Conduct clinical and non-clinical interviews, as necessary, to facilitate the investigative process. Work collaboratively with appropriate internal/external subject matter experts, agency and provider personnel, as necessary, to facilitate the investigative process.
  • Conducts clinical chart reviews of instances of care authorized for utilization purposes, case reviews for individuals that are identified as either over or under-utilizers of services.
  • Knowledge of documentation and clinical protocols for utilization purposes and case reviews for individual consumers in order to conduct clinical chart reviews.
  • Clinical knowledge of managed systems of Mental Health, Substance Abuse, and Intellectual Developmental Disabilities to also include co-occurring disorders. Knowledge of managed behavioral care practices and principles to detect fraud, waste and abuse.
  • Clinical ability to recognize gaps in Partners Behavioral Health Management service network and ability to communicate these identified gaps to appropriate parties.
  • Gather, evaluate, and synthesize evidence related to reported allegations to determine compliance with applicable state and federal policies, laws, and regulations.
  • Prepare timely, thorough, and accurate investigative reports; compile case file documentation; calculate overpayments; and synthesize findings in accordance with agency policies and procedures and departmental guidelines.
  • Communicate effectively, both in writing and orally, to ensure accurate and timely completion of all assignments.
  • Serve as a lead investigator responsible for coordinating and leading agency investigative teams related to program integrity.
  • Develop, implement, monitor, and maintain analytic reports to detect and prevent health care fraud, waste, and abuse.
  • Conduct independent data mining and data analysis techniques utilizing claims data to detect abnormal claims and develop trends and patterns for potential cases.
  • Independently prepare case documents for referral to the appropriate oversight agency and other external agencies involved in the prosecution of health care fraud.
  • Create, maintain, and manage cases within the case filing and tracking systems to ensure information is accurate, timely and complete.
  • Consult with legal counsel in order to prepare testimony and other information requested by external agencies investigating or prosecuting Medicaid fraud (as appropriate).
  • Remain abreast of all federal and North Carolina rules and laws applicable to fraud and abuse and program integrity.      
  • Develop, coordinate, and facilitate educational training to the Provider Network and agency personnel on issues relating to the compliance program, fraud, waste, and abuse.
  • Identify information system edits/alerts/reports in need of implementation in the claims processing system(s).
  • Recommend and implement compliance initiatives, policies, procedures, and practices designed to promote and encourage the reporting of suspected fraud, waste, and abuse without fear of retaliation.
  • Serve on and/or facilitate various agency committees as deemed necessary by the Program Integrity Director
  • Utilize data collection instruments and protocols previously developed or adopted by the department and develop data collection instruments as needed for complex investigations.
  • Analyze computer-generated data sets, including claims data, to identify individuals and organizations that are most likely to provide evidence to ascertain whether fraud or abuse is likely to have occurred.
  • Development of summary reports that illustrate data analysis to a nonscientific audience.
  • Utilize the CMS RAT-STATS program or other designated statistical sampling program and effectively apply appropriate sampling methodology for random sampling functions within the Program Integrity Department.
  • Consult with IT to manage data and generate needed program reports.
  • Perform other duties as assigned.




Knowledge, Skills and Abilities:

  • Strong knowledge of state and federal laws, including those related to Medicaid fraud, waste, abuse, and regulatory compliance are required.      
  • Knowledge of investigative methods and procedures.
  • Knowledge of claims processing and clinical services.
  • Excellent interpersonal and communication skills.
  • Excellent analytical skills.
  • Effective time management and organizational skills.
  • Excellent conflict management skills.
  • Proficient in Word, Excel, and Power Point.
  • Ability to learn and effectively manage various information systems.
  • Ability to develop solutions and make recommendations for necessary process improvements.
  • Ability to interpret contractual agreements, business oriented statistics, clinical/administrative services and records.
  • A high level of integrity and discretion is required to effectively carry out the responsibilities related to this position.



Education and Experience Required:

Master’s Degree in a Human Services field, Health Administration, health informatics/analytics, or related field. Minimum of 3 years recent experience in MH/IDD/SU, with compliance monitoring, auditing or investigation experience. Licensed Clinical Social Worker, Licensed Clinical Addiction Specialist, or another clinical license related to the MH/IDD/SU field. A valid driver’s license.


Education and Experience Preferred:

Five years recent experience in MH/IDD/SU. Experience analyzing complex data, claims processing, utilization reviews, provider credentialing/monitoring, and/or fraud and abuse detection. Preferred credentials: Registered Health Information Technician (RHIT); Registered Health Information Administrator (RHIA); Certified Coding Specialist (CCS); certified as an investigator/inspector through the Council on Licensure, Enforcement, and Regulation (CLEAR); Certified Fraud Examiner (CFE); and/or Accredited Healthcare Fraud Investigator (AHFI) certification. Experience with statistical methods preferred.


Licensure/Certification Requirements:

See required Education and Experience Required.




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