SIU Lead Investigator (Must live in Ohio) AHFI or CFE Required

Job Summary:

The SIU Lead Investigator is the face of the SIU department 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 fraud, waste, and abuse (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.

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 Plan
• Develop and implement innovative best practices to align with future growth and ongoing regulatory oversight
• Act as the Program Integrity liaison and ensure collaboration with state and federal agencies
• Engage 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 CareSource
• Identify opportunities for cost avoidance through prepayment review, provider education, or other preventative measures
• Responsible for regulatory reporting accuracy and other ad hoc regulatory inquiries
• Lead investigation on-sites as needed
• Conduct and assist investigators with complex investigations as needed
• Generate graphics that effectively describe, explore and summarize analysis for communication to appropriate parties
• 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
• 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
• 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
• Provide counsel and direction pertaining to state and federal laws, rules, and billing guidelines for various provider specialty types
• Coordinate and conduct meetings with operational departments, business partners, and regulatory partners to facilitate investigative case development
• Coordinate and conduct 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 litigation
• 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 ten (10) 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 Office, including Excel, Access, Word and PowerPoint
• SAS and SQL skills and experience for analytics projects, including database queries preferred
• OIG/ FBI/MFCU knowledge and experience
• 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 multiple Medicaid, Medicare and managed care plans
• 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:

• The following certifications are required: Accredited Healthcare Fraud Investigator (AHFI) certification and Certified Fraud Examiner (CFE), and Certified Professional Coder (CPC)
• NHCAA or other fraud and abuse investigations training is preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Occasional travel (up to 10%) to attend meetings, training, and conferences may be required

Compensation Range:
$79,800.00 - $127,600.00 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. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type:
Salary

Competencies:
- Create an Inclusive Environment
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business

This 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 inclusive environment that welcomes and supports individuals of all backgrounds.