Program Integrity Investigative Coordinator I

Job not on LinkedIn

🔥 19 hours ago

🇺🇸 United States – Remote

💵 $41.2k - $66k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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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

• Monitor and maintain all SIU fraud reporting mechanisms (hotline, facets routing, fax, emails) to ensure compliance with regulatory requirements • 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 other individuals to obtain information relevant to FWA investigations • Review claims for irregular billing patterns and consult specialists when necessary • Generate reports using multiple fraud detection software systems • Conduct rudimentary data analysis to determine financial exposure or risk to FWA allegations across all lines of business • Maintain anonymity and confidentiality throughout the intake process • Identify billing errors and accidental overpayments and initiate corrective action through the Research and Resolution Submission portal • Request medical records as needed and as directed by the Team Lead; partner with Clinical staff to resolve issues • Assist Program Integrity in overseeing Delegated Entities by routing state-directed correspondence and generating claims data reports • Prepare and document Attestations, De-conflictions, and Additional Allegation FWA informational letters for state Medicaid agencies • Attend state Medicaid investigative meetings to transcribe updates from the Attorney General’s Office and update applicable cases • Verify completion of state/federal directed provider removals • Maintain accurate database information in the Case Management System and verify provider information with Facets and the Medicaid Information Technology System • Uphold the Corporate Compliance Plan • Perform other job-related instructions as requested

🎯 Requirements

• High School Diploma or GED is required • Minimum of three (3) years’ experience in a health care related field or Customer Service is required • Associate’s Degree in Health-Related Field, Law Enforcement, or Insurance is preferred • Health care experience preferred (medical/dental claims, auditing, medical office experience, etc.) • 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 • No licensure or certification required

🏖️ Benefits

• Bonus tied to company and individual performance • Substantial and comprehensive total rewards package • Employee total well-being support