Medicaid/Medicare Program Integrity… at CoventBridge… · Remote

Summary: CoventBridge Group is a global leader in full-service investigations, and they are seeking a Medicaid/Medicare Program Integrity Analyst II to evaluate and develop leads, complaints, and investigations related to potential fraud. The role involves conducting independent reviews, utilizing data analysis techniques, and preparing reports and correspondence regarding fraud and abuse in healthcare delivery. Responsibilities: - Perform evaluation and development of leads, complaints, and/or investigations to determine if further investigation and administrative actions are warranted - Conduct independent reviews resulting from the discovery of situations that potentially involve fraud or abuse - Utilize basic data analysis techniques to detect aberrancies in Medicare and Medicaid claims data, and proactively seeks out and develops leads/investigations received from a variety of sources (e.g., CMS, OIG, 1-800-MEDICARE, and fraud alerts) - Review information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare and Medicaid policies and initiate appropriate action - Make potential fraud determinations by utilizing a variety of sources such as internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid regulations, and the Social Security Act - Compile and maintain documentation and information related to investigations, cases, and/or leads - Participate in onsite audits in conjunction with investigation development - Develop and prepare potential Fraud Alerts and program vulnerabilities for submission to CMS. Share information on current fraud investigations with other Medicare contractors and state Medicaid agencies, law enforcement, and other applicable stakeholders - Prepare and submit external correspondence and reports, including, but not limited to, overpayment letters, fraud case referrals, suspensions, rebuttals, Medicare/Medicaid findings reports, and administrative action recommendations - Submit suspension notifications to providers upon suspension approval - Prepare and submit ADR letters to providers associated with requests for medical record requests or suspension overpayment determinations - Serve as mentor/trainer to new Program Integrity staff - Perform other duties as assigned by PI Supervisor or PI Manager that contribute to task order goals and objectives Required Qualifications: - Excellent research and organization, prioritization, and time management skills - Excellent verbal and written communication skills - Ability to work independently with minimal supervision - Ability to multi-task in a fast-paced environment - High School Diploma or G.E.D. equivalent, with preference given to those candidates who have successfully completed college or technical degree programs related to the position (e.g., Criminal Justice, Statistics, Data Analysis, etc.) - At least 1 year of experience in Program Integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions Preferred Qualifications: - Knowledge of statistics, data analysis techniques, and PC skills are preferred - Candidates with Certified Fraud Examiner (CFE) Certifications will be given priority consideration Required Skills: Program Integrity investigation, Fraud detection, Data analysis techniques, Statistics, Certified Fraud Examiner (CFE) Certification, Medicare claims data, Medicaid claims data, Claims processing systems, Medicare, Medicaid regulations, Research, Prioritization, Multi-tasking Benefits: Medical, Dental, Vision plans, Life, LTD and STD paid by the employer, 401(k) with company match up to 4%, Paid Time Off and company paid holidays, Tuition assistance after 1 year of service