Program Integrity Investigative Coordinator I

Job Summary:

The Program Integrity Investigative Coordinator I monitors and maintains all SIU fraud reporting mechanisms (hotline, facets routing, fax, emails) to ensure compliance with regulatory requirements.
Essential Functions:

- Accurately load Fraud, Waste & Abuse (FWA) referrals into the SIU Case Management System

- Analyze FWA allegation facts and evaluate whether cases can be closed or escalated

- Interview claimants, providers, members or any other individuals to obtain information relevant to any FWA investigation

- Review claims for irregular billing patterns, consulting specialists when necessary

- Generate various reports utilizing multiple fraud detection software systems

- Conduct rudimentary data analysis to determine financial exposure or risk to FWA allegation across all lines of business

- Responsible for maintaining anonymity and confidentiality during all phases of intake process

- Independently identify billing errors and accidental overpayments initiating corrective action through the Research and Resolution Submission portal

- Request medical records on an as-needed basis and as directed by Team Lead; partner with Clinical staff to resolve any issues

- Assist Program Integrity in the oversight of Delegated Entities by routing state directed correspondence and generating claims data reports across all lines of business

- Prepare and document Attestations, De-conflictions and Additional Allegation FWA informational letters, as contractually required, for any state Medicaid agency

- Attend state Medicaid investigative meetings to transcribe updates provided by the Attorney General’s Office; update any applicable cases

- Support compliance and regulatory requirements by verifying all state/federal directed provider removals are completed accurately across all lines of business

- Drive accuracy of database information maintained in Case Management System; proactively verify the accuracy of provider information in concert with Facets and the Medicaid Information Technology System

- Know and uphold the provisions of the Corporate Compliance Plan

- Perform any other job related instructions as requested

Education and Experience:

- High School Diploma or GED is required

- Associate’s Degree in Health-Related Field, Law Enforcement, or Insurance is preferred

- Minimum of three (3) years’ experience in a health care related field or Customer Service is required

- Health care experience preferred (medical/dental claims, auditing, medical office experience, etc.)

Competencies, Knowledge and Skills:

- Intermediate computer skills consisting of Microsoft Excel, Access, Outlook, Word, and Power Point

- Ability to navigate multiple software systems at a high proficiency level

- Good communication skills

- Ability to work independently and within a team environment

- High attention to detail

- Critical listening and thinking skills

- Proper grammar usage

- Time management skills

- Proper phone etiquette

- Customer service oriented

- Decision making/problem solving skills

- Strong organization skills

- Customer service oriented

Licensure and Certification:
- None

Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time

Compensation Range:
$41,200.00 - $66,000.00
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 package.
Compensation Type (hourly/salary):
Hourly Organization Level Competencies

-
Fostering a Collaborative Workplace Culture

- Cultivate Partnerships

- Develop Self