Investigator I/II

Summary

Job Description:

This position is responsible for the accurate and thorough investigation of potential fraud and abuse for all lines of business. The scope of accountability includes investigating and remediating allegations of fraud, waste, and abuse (FWA) while adhering to compliance and regulatory requirements.

FWA investigative activities encompass cases within the Health Plan regions but will additionally involve cases outside the state which require coordination with Blues Plans nationwide, the national FEP Special Investigations Unit as well as multiple regulatory/investigative agencies across the country. International FWA is also inclusive of the scope when member services are rendered out of the country.

Essential Accountabilities

Level I

• Primary activities include substantiating referrals, case research and planning, conducting onsite or desk audits, reviews of medical records to ensure correct billing and
  
  

coding of services and appropriateness of care, interviewing potential witnesses, developing corrective action plans, developing correspondence to impacted parties,

managing disputes, and collaborating with law enforcement and regulatory agencies.

• Interprets a variety of documents including, but not limited to, provider and subscriber contracts, group benefit structures, Corporate Medical Policies, AMA CPT Coding
  
  

Guidelines, HCPCS Coding Guidelines, inter-plan regulations, government policies as well as diverse regulatory and legal requirements.

• Performs critical reviews of proactive detection reports and claims data to identify red flags/aberrant billing patterns.
• Solves problems using sound professional judgment to determine the appropriate course of action and independently follows through, when necessary.
• Thoroughly researches allegations or issues and develops sources of information to create a plan of action. Accumulates sufficient detailed evidence including
  
  

statements, documents, records, and exhibits. Evaluates situations accurately and interacts with management, medical directors and legal, where appropriate to ensure

complex issues are addressed appropriately.

• Collaborates with Medical Directors regarding investigation coding related decisions. Prepares comprehensive summary reports and prepares cases for prosecution or
  
  

civil settlement by documenting findings in a clear and concise manner.

• Completes documentation and data required for subpoenas or demand letters from law enforcement and regulators.
• Provides routine interaction and coordination with the BCBS Association Anti-fraud Department, Blue Plans serving members outside of Health Plan’s regions, Federal
  
  

Employee Program (FEP), Centers for Medicare & Medicaid Services (CMS), New York State (NYS) Department of Financial Services (DFS), NYS Department of Health

(DOH), NYS Office of the Medicaid Inspector General (OMIG), NYS Medicaid Fraud Control Unit, local, state, and federal law enforcement and prosecutorial agencies

and medical licensing boards.

• Maintains accurate and up-to-date knowledge of all Government Program regulations (Medicaid, Medicare, Federal Employee Program, etc.)
• Interacts frequently with members and providers of health care, often under adverse conditions due to discovery of FWA. Must be able to discuss sensitive material in a
  
  

professional, fair, and accurate manner.

• Acts as a primary point of contact with law enforcement for assigned cases and may be required to review files and testify in court in matters regarding litigation related to
  
  

their cases and reviews.

• Manages cases as assigned, prioritizing case load, as appropriate. Maintains case logs, prepares records and regular status reports.
• Assists in the development and adherence to unit standards for productivity, quality assurance and compliance. Prepares recommendations on preventive/corrective
  
  

measures for the deterrent of future fraud.

• Supports other SIU Investigators and Analysts with reports of potential FWA submitted through the Facets claims system workflow and through emails sent directly to the
  
  

SIU on an as needed basis.

• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct,
  
  

and leading to the Lifetime Way values and beliefs.

• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
  
  

Level II (in addition to Level I Accountabilities)

• Performs more complex investigations with less direct supervision. Performs compliance and/or governance on more complex special projects and audits.
• Offers process improvement suggestions and participates in the solution of more complex issues/activities.
• Provides consistent accurate, organized and well written audit results with minimal assistance from management.
• Provides and supports training or reference materials for SIU team members as appropriate. Mentors junior staff and assists with coaching, when necessary.
• Interfaces appropriately and independently with many different provider types, external agencies, other Blue Plans, and external business partners.
• Completes comprehensive summary of investigations for fraud and abuse referrals to NYS DFS, NYS DOH and/or NYS OMIG whenever necessary.
• Discerns when to suggest deviations from standard practices based on tangible and intangible factors.
• Participates on committees as assigned.
  
  

Level III (in addition to Level II Accountabilities)

• Independently manages the highest level of complex investigations, compliance, and regulatory issues and exercises decision-making in project work groups.
• Assesses potential non-compliance vulnerabilities, identifies root causes of issues, and provides practical business recommendations for corrections. Works with
  
  

business area staff, Compliance, and other internal departments as necessary to develop recommendations and reach meaningful and appropriate resolutions.

• Assists and/or leads the development and delivery of FWA awareness activities and trainings for the Health Plan.
• Serves as an initial point of escalation for Level I and II Investigators on complex issues/questions.
• Provides back-up for SIU Managers, whenever necessary.
  
  

Minimum Qualifications

NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

All Levels

• MUST meet the NYS DFS’s and the NYS OMIG’s minimum Investigator requirements as follows:
  
  

Persons employed by the SIU as Investigators shall be qualified by education or experience, which shall include:

• A minimum of five years in the healthcare field working in FWA investigations and audits; or
• five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies; or
• seven years of professional investigation experience involving economic or insurance related matters; or
• an associate or bachelor's degree in criminal justice or related field; or
• employment as an Investigator in the SIU on or before December 28, 2022.
• Certified Professional Coder, Accredited Health Care Fraud Investigator, Certified Fraud Examiner, or comparable certification required. If candidate does not possess
  
  

certification, must obtain within two years of hire date.

• Comprehensive knowledge of the criminal justice systems and applicable laws, rules, and mandates, with emphasis on economic crime investigations and related
  
  

criminal investigations, knowledge of claims processing systems, contracts, and riders.

• Knowledge of the health care insurance industry, extensive knowledge of member and provider contracts and claims processing including InterPlan rules for all lines of
  
  

business.

• Knowledge of the technical and operational areas within the Health Plan and a demonstrated ability to effectively utilize internal resources to facilitate issue resolution.
• Understanding of the legal and regulatory processes as it applies to a commercial and government business/insurance environment.
• Demonstrates excellent organization, oral and communication skills. Demonstrates proficient analytical and writing skills for the creation of professional documents.
• Demonstrates proficient computer skills utilizing software programs such as Word, Excel and/or PowerPoint.
• Excellent interpersonal skills.
• Ability to multi-task and balance priorities.
  
  

Level II (in Addition To Level I Qualifications)

• Two or more years of experience in the Investigator role and ability to perform all functions with minimal supervision.
• Expertise in the technology of the job.
• Excellent understanding of contract benefits, electronic data processing systems, and corporate policies and procedures.
• Excellent ability to determine State and Federal fraudulent activity and compile necessary documentation for prosecution presentation. Ability to explain and interpret
  
  

these findings to law enforcement authorities in a comprehensive manner.

• Demonstrated ability to professionally interact with providers and outside regulatory agencies independently with little or no management intervention on issues of
  
  

modifying provider billing behavior or collaborating on cases.

• Ability to provide clear and concise presentations and effectively communicate complex information to diverse audiences.
• Ability to interpret laws and regulations pertinent to a case and appropriately communicate these findings to law enforcement and prosecutors.
• Demonstrated superior oral communication skills, strong presentation skills, and strong writing skills for the creation of comprehensive professional documents.
• Strong dispute resolution and negotiation skills in order to interface appropriately with many different provider types, attorneys, other Blue Plans and external agencies
  
  

and business partners.

• Proficient with health systems operations including an understanding of reimbursement methodologies and coding conventions for governmental and commercial
  
  

products (e.g., Medicare, Medicaid, CPT, HCPCS, ICD10, DRG, APC, RBRVS, etc.).

• Extensive experience with claims processing systems, claims flow, adjudication process, system edits and display screens.
  
  

Level III (in Addition To Level II Qualifications)

• Five or more years of experience in the Investigator role.
• Subject matter expert in health systems operations including an understanding of reimbursement methodologies and coding conventions for governmental and
  
  

commercial products (e.g., Medicare, Medicaid, CPT, HCPCS, ICD10, DRG, APC, RBRVS, etc.).

• Comprehensive understanding of multiple functional areas (i.e. SIU, Legal, Regulatory Compliance, Operations) and supporting systems. (BREADTH).
• Expertise in complex/difficult investigations and highly visible issues. (DEPTH).
• Comprehensive knowledge of the health care insurance industry and investigation concepts and principles.
• Proven ability to successfully prioritize and manage multiple projects simultaneously.
• Displays leadership abilities and serves as a positive role model to others in the department.
• Lead the training of new staff and provide feedback to management for evaluation.
• Demonstrates superior oral communication skills, excellent presentation skills and excellent writing skills for the creation of comprehensive professional documents.
  
  

Physical Requirements

• Ability to work prolonged periods sitting and/or standing at a workstation viewing a computer and using a keyboard, mouse and/or phone.
• Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
  
  

One Mission. One Vision. One I.D.E.A. One you.

Together we can create a better I.D.E.A. for our communities.

At the Lifetime Healthcare Companies, we’re on a mission to make our communities healthier, and we can’t do it without you. We know diversity helps fuel our mission and that’s why we approach our work from an I.D.E.A. mindset (Inclusion, Diversity, Equity, and Access). By activating our employees' experiences, skills, and perspectives, we take action toward greater health equity.

We aspire to reflect the communities we live in and serve, and strongly encourage people of color, LGBTQ people, people with disabilities, veterans, and other underrepresented groups to apply.

Our Company Culture

Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s)

Level I (E2): Minimum: $60,410 - Maximum: $96,081

Level II (E4): Minimum: $65,346 - Maximum: $117,622

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.