Program Integrity Clinical Investigator; Remote-NC

Competitive Compensation & Benefits Package

Competitive Compensation & Benefits Package!

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs
• Public Service Loan Forgiveness Qualifying Employer

See attachment for additional details.

Flexible for any of our NC office locations (Must live in NC or within 40 miles of NC border)

Depending on Experience

Open Until Filled

This position will assist in the development, implementation, revision, maintenance, and promotion of the agency’s fraud, waste, and abuse prevention and detection activities to ensure that the agency and the agency’s network operates in a manner that complies with applicable State and Federal laws, regulations, agency policies, national accreditation, and Medicaid guidelines. This position will perform functions relating to data analysis, investigations, and auditing relating to the monitoring, detection, and resolution of healthcare fraud, waste, and abuse.

• Conduct, plan and perform independent and comprehensive audits, investigations and reviews (hereinafter referred to as investigations) into allegations of regulatory compliance violations, including fraud, waste, and abuse (FWA). Investigation includes the review of financial, consumer/clinical, provider, and/or other records, reports, and information necessary to thoroughly analyze and investigate suspected violations.
• Conduct clinical and non-clinical interviews, as necessary, to facilitate the investigative process. Work collaboratively with appropriate internal/external subject matter experts, agency and provider personnel, as necessary, to facilitate the investigative process.
• Conducts clinical chart reviews of instances of care authorized for utilization purposes, case reviews for individuals that are identified as either over or under-utilizers of services.
• Knowledge of documentation and clinical protocols for utilization purposes and case reviews for individual consumers in order to conduct clinical chart reviews.
• Clinical knowledge of managed systems of physical health services (professional and institutional), durable medical equipment, pharmacy, Mental Health, substance abuse, and Intellectual and Developmental Disabilities to also include co-occurring disorders. Knowledge of managed care practices and principles to detect fraud, waste and abuse.
• Clinical ability to recognize gaps in Partners Health Management service network and ability to communicate these identified gaps to appropriate parties.
• Serve as a Lead Investigator responsible for coordinating and leading agency investigative teams related to program integrity.
• Gather, evaluate, and synthesize evidence related to reported allegations to determine compliance with applicable state and federal policies, laws, and regulations.
• Prepare written and oral reports based on the results of assigned work that help to sustain findings and uphold disputed TNOs.
• Prepare timely, thorough, and accurate investigative reports; compile case file documentation; calculate over payments; and synthesize findings in accordance with agency policies and procedures and departmental guidelines.
• Communicate effectively, both in writing and orally, to ensure accurate and timely completion of all assignments.
• Develop, implement, monitor, and maintain analytic reports to detect and prevent health care FWA.
• Conduct independent data mining and data analysis techniques utilizing claims data to detect abnormal claims and develop trends and patterns for potential cases.
• Independently prepare case documents for referral to the appropriate oversight agency and other external agencies involved in the prosecution of health care fraud.
• Manage cases from complaint intake through their ultimate conclusion, including supporting the case during all legal processes and appeals and the collection of final over payments.
• Create,…