The Program Integrity Investigative Coordinator I monitors and maintains all SIU fraud reporting mechanisms (hotline, facets routing, fax, emails) to ensure compliance with regulatory requirements.Essential Functions:Accurately load Fraud, Waste & Abuse (FWA) referrals into the SIU Case Management SystemAnalyze FWA allegation facts and evaluate whether cases can be closed or escalatedInterview claimants, providers, members or any other individuals to obtain information relevant to any FWA investigationReview claims for irregular billing patterns, consulting specialists when necessaryGenerate various reports utilizing multiple fraud detection software systemsConduct rudimentary data analysis to determine financial exposure or risk to FWA allegation across all lines of businessResponsible for maintaining anonymity and confidentiality during all phases of intake processIndependently identify billing errors and accidental overpayments initiating corrective action through the Research and Resolution Submission portalRequest medical records on an as-needed basis and as directed by Team Lead; partner with Clinical staff to resolve any issuesAssist Program Integrity in the oversight of Delegated Entities by routing state directed correspondence and generating claims data reports across all lines of businessPrepare and document Attestations, De-conflictions and Additional Allegation FWA informational letters, as contractually required, for any state Medicaid agencyAttend state Medicaid investigative meetings to transcribe updates provided by the Attorney General’s Office; update any applicable casesSupport compliance and regulatory requirements by verifying all state/federal directed provider removals are completed accurately across all lines of businessDrive accuracy of database information maintained in Case Management System; proactively verify the accuracy of provider information in concert with Facets and the Medicaid Information Technology SystemKnow and uphold the provisions of the Corporate Compliance PlanPerform any other job related instructions as requestedEducation and Experience:High School Diploma or GED is requiredAssociate’s Degree in Health-Related Field, Law Enforcement, or Insurance is preferredMinimum of three (3) years’ experience in a health care related field or Customer Service is requiredHealth care experience preferred (medical/dental claims, auditing, medical office experience, etc.)Competencies, Knowledge and Skills:Intermediate computer skills consisting of Microsoft Excel, Access, Outlook, Word, and Power PointAbility to navigate multiple software systems at a high proficiency levelGood communication skillsAbility to work independently and within a team environmentHigh attention to detailCritical listening and thinking skillsProper grammar usageTime management skillsProper phone etiquetteCustomer service orientedDecision making/problem solving skillsStrong organization skillsCustomer service orientedWorking Conditions:General office environment; may be required to sit or stand for extended periods of timeIn addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Program Integrity Investigative Coordinator I

Emma

Responsibilities

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Admin access needed