SIU Investigator III (Must live in MA or surrounding states)

CareSource Management Services LLC • Dayton, OH • 1w ago

Job Summary:
The Special Investigations Unit (SIU) III is responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professional, facilities, and members. Researches, gathers, and analyzes data to identify trends, patterns, aberrancies, and outliers in provider billing behavior. Serves as a subject matter expert for other investigators. Qualified candidates must live in Massachusetts or surrounding states.
Essential Functions:
Develop, coordinate and conduct strategic fact-driven investigative projects including business process review, execution of investigative activities, and development of investigation outcome recommendations
Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data and translate analytical findings into actionable items
Manage strategic investigative plan and drive investigative outcome for the team
Ensure quality outcomes for investigative team through auditing and oversight
Prioritize, track, and report status of investigations
Report identified corporate financial impact issues
Use concepts and knowledge of coding guidelines to analyze complex provider claim submissions
Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines
Identify, research and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approach
Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling
Coordinate and conduct on-site and desk audits of medical record reviews and claim audits
Manage and decision claims pended for investigative purposes
Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty @types
Prepare and conduct in-depth complex interviews relevant to investigative plan
Execute and manage provider formal corrective action plans
Participate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case development
Participate in 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
Present, support, and defend investigative research to seek approval for formal corrective actions
Establish and maintain relationships with Federal and State law enforcement agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention
SME in the designated market and ability to apply external intelligence to their analysis and case development
Develop and present internal and external formal presentations, as needed
Attend fraud, waste, and abuse training/conferences, as needed
Support regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agencies
Manage and maintain sensitive confidential investigative information
Maintain compliance with state and federal laws and regulations and contracts
Adhere to the CareSource Corporate Compliance Plan and the Anti-Fraud Plan
Assist in Federal and State regulatory audits, as needed
Perform any other job-related instructions, as requested
Education and Experience:
Bachelor's Degree or equivalent years of relevant work experience in Health-Related Field, Law Enforcement, or Insurance required
Master's Degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing) preferred
Minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics or related field is required
Competencies, Knowledge and Skill

Similar Jobs

Strategic Customer Success Manager

Trimble Inc • Dayton, OH • 33min ago

Management & Administrative

Propel Customer Value: Strategic Customer Success Manager - Transportation & Logistics This critical role in our Transportation & Logistics segment is for a strategic leader ready to forge thriving, long-term par...

33min ago

Go to Apply

Manufacturing / Production Engineer - Senior

Modern Technology Solutions, Inc. • Dayton, OH • 34min ago

IT & Engineering

Modern Technology Solutions, Inc. (MTSI) is seeking a Manufacturing / Production - Senior at Wright-Patterson AFB, OH. As aSenior Production & Manufacturing Engineer, you will play a key role in guiding and executing...

34min ago

Go to Apply

Physical Therapist Assistant

Select Medical • Springfield, OH • 1h ago

Hospital & Medical

Overview Position: Physical Therapist Assistant Location: 1303 W 1st St Springfield, OH 45504 Type of Employment: Full-time Schedule: Monday - Thursday (8am-6pm), Friday (8am-12pm) Compensation: Starting at $24/hr, comme...

1h ago

Go to Apply

Physical Therapist - $20K Sign-on Bonus

Select Medical • Beavercreek, OH • 2h ago

Hospital & Medical

Overview Position: Physical Therapist Location: 2655 Commons Boulevard Beavercreek, OH 45431 Type of Employment: Full-time Schedule: Weekdays (Hours Vary) Compensation: $72,000 - $85,000, annually,based on years of exper...

2h ago

Go to Apply

Ambulatory Nurse-ENT

Dayton Children's Hospital • Dayton, OH • 2h ago

Hospital & Medical

Facility:Dayton Children's - Main CampusDepartment:Pediatric ENT ClinicSchedule:Full timeHours:40Job Details:The Ambulatory Nurse is a nursing staff position, which reports to the Administrative Manager. Performs treatme...

2h ago

Go to Apply

Entry Level Data Visualization & Database Specialist

Reynolds & Reynolds • Dayton, OH • 3h ago

Management & Administrative

Position Description We are looking for a knowledgeable and motivated professional with a background in data analysis, data visualization, or database management to join our growing team. As a member of our Remote Softwa...

3h ago

Go to Apply

Warehouse Worker

Adecco US, Inc. • Union, OH • 3h ago

Manufacturing & Warehouse

Adecco is hiring immediately for Warehouse Workers at a local client in Vandalia, OH. Warehouse Workers do essential jobs with one of our premier clients, with starting pay at $15.00-$ 15.50 /hr., plus available overtime...

3h ago

Go to Apply

$23hr - Production (Plated Coatings) 2nd shift

Hohman Plating. LLC • Dayton, OH • 4h ago

Manufacturing & Warehouse

**We have been in business 106 years, conveniently located 1 mile north of downtown Dayton. Training on 1st shift up to 90 days, M-F 7am-3:30pm. $20hr 2nd shift hours - M-F, 3pm - 11:30pm $23hr SUMMARY OF JOB Responsible...

4h ago

Go to Apply

$22hr - Production (Plated Coatings) 3rd shift

Hohman Plating. LLC • Dayton, OH • 4h ago

Manufacturing & Warehouse

**We have been in business 106 years, conveniently located 1 mile north of downtown Dayton. Training on 1st shift up to 90 days, M-F 7am-3:30pm. $20hr 3rd shift hours - Sunday PM to Friday AM - 11:30pm - 7:30am. $22hr SU...

4h ago

Go to Apply

1st & 3rd Shift General Laborer

Aerotek • Middletown, OH • 4h ago

Manufacturing & Warehouse

1st & 3rd shift General Production Worker $20.69-$26/HR -- Overtime Available! 7 days PER WEEK Apply then text Nate @ (513) 229-2014 Job Description This entry-level role offers an opportunity to join the manufacturi...

4h ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.