• Program Integrity Investigator

    Job Locations US-NC-Gastonia
    Posted Date 1 month ago(3/19/2018 5:52 PM)
    Job ID
    # of Openings
    Community and Social Services
  • Overview

    Excellent Benefits Package!!!

    Projected Hiring Range:  $42,940 - $45,200



    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 in an effort to ensure that the agency and the agency’s network operates in a manner that is in compliance with applicable State and Federal 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. Investigation includes the review of financial, consumer/clinical, provider, and/or other records, reports, and information necessary to thoroughly analyze suspected violations.
    • Conduct 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.
    • Gather, evaluate, and synthesize evidence related to reported allegations in order to determine compliance with applicable state and federal policies, laws, and regulations.
    • Develop reports of investigative findings, compile case file documentation, calculate overpayments, and issue findings in accordance with agency policies and procedures Communicate effectively, both in writing and orally, to ensure accurate and timely completion of all support staff 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 for the purpose of detecting and preventing healthcare fraud, waste, and abuse.
    • Conduct independent data mining and data analysis techniques utilizing claims data to detect aberrancies and outliers in 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 tracking system to ensure information is accurate and timely.
    • 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.
    • 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 Division 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 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:

    Bachelor’s Degree in a Human Services field, Health Administration, health informatics/analytics, or related field. Minimum of three (3) years recent experience in MH/DD/SU, with compliance monitoring, auditing or investigation experience.


    Education and Experience Preferred:

     5 years recent experience in MH/DD/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), and/or certified as an investigator/inspector through the Council on Licensure, Enforcement, and Regulation (CLEAR). Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) certification. Licensed Clinical Social Worker, Licensed Clinical Addiction Specialist, or another clinical license related to the MH/IDD/SU field. Experience with statistical methods preferred.


    Licensure/Certification Requirements: N/A


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