Providing compliance oversight of the Managed Care Plans (MCPs) participating in the Statewide Medicaid Managed Care program to ensure they are meeting program integrity requirements set forth in state and federal law, as well as the provisions of contract and Medicaid policy.
Conducting investigations into possible fraud or abuse committed by the MCPs or their provider networks.
Responsible for conducting investigations/audits, visiting providers, identifying overpayments, writing investigative summary reports, and making recommendations for referrals to other entities involving Medicaid providers or issuing audit reports in accordance with state and federal rules, laws, and statutes.
Required to collaborate with other MPI operational units and regulatory agencies as well as to participate in joint data driven field initiatives and special projects.
Responsible for utilizing open-source and proprietary resources to conduct investigations/audits and related administrative actions, as well as monitoring and tracking the associated case status.
Conducting payment restriction reviews in accordance with state and federal rules, laws, and statutes.

Requirements

Two years of professional or nonprofessional experience in a regulatory or health service setting.
An associate’s degree from an accredited college or university can substitute on a year for year basis in a related field such as health law, health science, health services administration, business administration, public administration, sociology, criminology, criminal justice, or a substantially similar discipline.
Preference will be given to candidates with a program integrity related professional certification, such as: Certified Fraud Examiner; Accredited Healthcare Fraud Investigator; Certified Financial Crimes Investigator; Certified Insurance Fraud Investigator; Certified Compliance and Ethics Professional, or other relevant certification, such as: Project Management Professional.
Preference will be given to candidates with professional experience in business, or information analysis.

Benefits

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Applicant Tracking System Keywords

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Hard Skills & Tools

investigationsauditscompliance oversightpayment restriction reviewsdata analysisreport writingcase monitoringoverpayment identificationadministrative actionsprogram integrity

Soft Skills

collaborationcommunicationrecommendation makingproblem-solvingattention to detailorganizational skillsinterpersonal skillsanalytical thinkingproject participationinitiative

Certifications

Certified Fraud ExaminerAccredited Healthcare Fraud InvestigatorCertified Financial Crimes InvestigatorCertified Insurance Fraud InvestigatorCertified Compliance and Ethics ProfessionalProject Management Professional