Lead Investigator

🔥 12 hours ago

🍑 Georgia – Remote

🍑 Georgia – Remote

💵 $83k - $132.8k / year

⏰ Full Time

🟠 Senior

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Serve as the face of the Special Investigations Unit with external federal and state regulatory agencies • Manage regulatory communications and ensure timely oversight-agency responses • Identify and monitor emerging fraud, waste, and abuse trends • Research claims, industry sources, and internal and external data to identify potential fraud • Use data analytics platforms to mine large data volumes and identify fraudulent activity, patterns, and billing anomalies • Develop and monitor the Annual Program Integrity Fraud, Waste and Abuse Plan • Develop and implement innovative best practices aligned with growth and regulatory oversight • Act as Program Integrity liaison with state and federal agencies • Support deployment and monitoring of state-specific regulations for Medicaid and Medicare programs • Build relationships through external fraud associations and industry partnerships • Identify cost-avoidance opportunities through prepayment review, provider education, and preventive measures • Ensure accuracy of regulatory reporting and respond to regulatory inquiries • Ensure high-volume, quality FWA referrals to state partners • Lead investigation on-sites and mentor the team • Conduct and assist with complex investigations • Collaborate with data analytics teams and use RAT-STATS for statistically valid random sampling • Manage investigation turnaround times and case documentation quality • Generate and trend fraud-detection leads to identify quality-improvement and focused-investigation opportunities • Identify trends and patterns using corporate processes, tools, reports, databases, policies, coding guidelines, and regulations • Manage and make decisions on claims pended for investigation • Maintain knowledge of state and federal laws, rules, and provider billing guidelines • Prepare and conduct in-depth complex interviews • Execute and manage provider corrective action plans • Participate in meetings with operational, business, legal, and regulatory partners • Support legal actions, corrective actions, negotiations, recoveries, settlements, and evidentiary-document preparation • Design data-analysis strategies for quality improvement and focused investigations • Monitor media and state and federal press releases for emerging schemes and exposure • Lead information-sharing activities and produce actionable data analyses • Manage confidential investigative information • Maintain compliance with laws, regulations, contracts, the Corporate Compliance Plan, and Anti-Fraud Plan • Assist with federal and state regulatory audits • Perform other job-related duties as requested

🎯 Requirements

• Bachelor’s Degree or equivalent years of relevant work experience in Fraud & Abuse Investigations required • Minimum of 10 years of experience in Healthcare Fraud, Healthcare data analysis, or Compliance required • Two of the following required: Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Certified Professional Coder (CPC), or 6 years of coding experience • Proven analytic skills in solving multi-dimensional problems • Advanced Microsoft Applications experience, including Excel, Access, Word, and PowerPoint • SAS and SQL skills and experience for analytics projects preferred • OIG/FBI/MFCU knowledge and experience • Knowledge of inferential statistics • Working knowledge of descriptive statistical applications and techniques • Critical listening, thinking, verbal, and written communication skills • Decision-making and 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 procedure and diagnosis codes including CPT, ICD-10, HCPCS, APC, and DRGs • Knowledge of value-based reimbursement methodology • Ability to lead analytic efforts • Master’s Degree preferred • Previous law enforcement experience preferred

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Occasional travel to meetings, training, and conferences

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