Healthcare Marketplace Senior Investigator Remote

Integrity Management Services, Inc. (Integrity

M) is a woman-owned small business specializing in assisting government healthcare organizations prevent and detect fraud and abuse in their programs. At Integrity

M, we offer a culture of opportunity, recognition, and collaboration. We thrive off of these fundamental elements that make Integrity

M a great place to work. We offer the flexibility our employees need to challenge themselves and focus on advancing their professional development and careers. Large company perks. Small company feel.

In this role, the Marketplace Senior Investigator will provide investigative services to safeguard the integrity of the health insurance Marketplace authorized by the Affordable Care Act (ACA). The Marketplace Senior Investigator will use a variety of tools to initiate investigations, identify subjects and develop cases for future action, including a referral to law enforcement, education, over payment recovery and other administrative actions that follow the Marketplace rules, requirements and laws.

The Marketplace Senior Investigator works independently as well as collaboratively with various team members and managers.

• Conduct background research of suspect agents/brokers to identify information regarding adverse business relationships, disqualifying violations, exclusions or licensing sanctions.
• Conduct data analysis to identify instances of suspected healthcare fraud, waste, and abuse.
• Identify data anomalies that lead to new project priorities.
• Review policies, regulations and instructions relevant to supporting suspected healthcare fraud, waste and abuse violations and provide that information as necessary in support of data analysis findings.
• Document all findings relevant to support recommendations for further analysis or investigation referrals.
• Analyze and evaluate enrollment data related to consumer and Agent/Broker activity within the Marketplace.
• Collect and review records and documents relevant to investigation development.
• Conduct interviews and maintain accountability and safeguards of any items considered to be of evidentiary value in accordance with established guidelines and rules of evidence.
• Coordinate investigations with appropriate federal and state law enforcement agencies, legal counsel and state and federal program administration agencies.
• Coordinate within a team of ACA policy subject matter experts (SMEs), data analysts, program managers, and other staff as appropriate to develop or uncover investigations.
• Input data into appropriate database tracking programs as needed in accordance with established rules.
• Coordinate with clients in support of findings and recommendations resulting from investigations and data analysis.
• Provide input into development of new fraud scheme studies.
• Actively support preparation of comprehensive reports on the status of leads and investigations as required by CMS.
• Meet all established deadlines.
• Work with internal resources and external agencies to develop cases and corrective actions, as well as respond to requests for data and support.
• Maintain fraud case development quality standards so that proper case development is ensured and quality cases are fully prepared.
• Maintain proper and timely updates in appropriate tools and applications for investigations (case development databases and documents).
• Complete all requests for information from law enforcement within required time frames.
• Enhance fraud detection and improve interdepartmental workflow so that the client is proactive in identifying potentially fraudulent schemes.
• Conduct on-site visits and/or interviews as required for investigation.
• Perform ad hoc tasks/duties as assigned.
• Ensure compliance with all applicable privacy and security training requirements (both Integrity
  
  M and external/client-based), whether on an annual or ad-hoc basis. Certain position levels (leads, managers, directors or higher) may require additional “role‑based” training to ensure compliance with applicable privacy and security requirements.
• Exercise appropriate discretion and independent judgment relating to company policies and practices in an effective, consistent and…