Immediate need for a Medicaid/ Medicare Program Integrity Analyst within the largest worldwide investigative solutions company. Join us as we continue our expansion into all areas of investigations, allowing continual growth for all employees. The analyst will primarily be responsible for performing investigations, site visits once evaluations and developments of complaints determine an investigation is warranted.
Our company's mission with this position is to provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste, and abuse. This position will report directly to the Program Integrity Supervisor and will work in our Grove City, OH office or if not local, remotely from a home office.
- Perform evaluation and development of complaints to determine if referral as an investigation is 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 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 initiates 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 and Medicaid contractors, law enforcement, and other applicable stakeholders
- Perform other duties as assigned by PI Supervisor or PI Manager that contribute to task order goals and objectives
- 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.
- Excellent oral, written and verbal skills
- Ability to work independently with minimal supervision
- Knowledge of statistics, data analysis techniques, and PC skills are preferred
- Experience with Microsoft Excel preferred
- Full COVID-19 vaccination and documentation are required as this position directly or indirectly supports a Federal Government Contract. [2 doses of Moderna or Pfizer; 1 dose of Johnson & Johnson]. Medical and religious accommodations are considered for exemption.