- Fraud, Waste, and Abuse Detection
- Analyze Medicaid and Medicare Advantage claims data to identify patterns, anomalies, and trends indicative of potential fraud, waste, or abuse.
- Develop and implement data mining techniques and predictive analytics models to detect suspicious activities.
- Monitor provider and member behavior to identify irregularities requiring further investigation.
- Investigation of Allegations
- Conduct detailed investigations of suspected fraud, waste, and abuse, including reviewing claims, medical records, and other supporting documentation.
- Collaborate with internal departments, such as Compliance, Legal, and Medical Management, to gather information and corroborate findings.
- Prepare comprehensive investigative reports detailing findings, methodologies, and recommendations for corrective actions.
- Regulatory Compliance
- Ensure investigative practices and procedures comply with federal and state laws, including S. 409.913 and Chapter 817, as well as CMS guidelines.
- Maintain detailed records of all investigations to support reporting requirements to regulatory agencies and partners.
- Assist in developing and maintaining policies and procedures for fraud prevention and investigation.
- Data Analysis and Reporting
- Utilize advanced data analytics tools to extract, organize, and interpret claims data.
- Prepare and present analytical reports to senior leadership and external stakeholders, including managed care partners and regulatory agencies.
- Support the development of dashboards and metrics to monitor program integrity performance.
- Training and Collaboration
- Provide training and education to staff on fraud, waste, and abuse detection and prevention techniques.
- Collaborate with external organizations, such as law enforcement and other SIUs, to enhance investigation efforts and share best practices.
- Participate in cross-functional committees and workgroups focused on program integrity.
- Continuous Improvement
- Stay informed of industry trends, regulatory updates, and emerging threats related to health care fraud.
- Recommend and implement enhancements to investigative tools, processes, and methodologies.
Education and Experience - Bachelor’s degree in Criminal Justice, Data Analytics, Health Administration, or a related field.
- Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), or similar certification preferred.
Minimum of 3 years of experience in health care fraud investigations, insurance claims analysis, or a related role. Experience working with law enforcement, offices of inspector general, Medicaid Fraud Control Units, or other regulatory bodies in health care fraud investigations preferred.
Required Skills
- Proficient in Microsoft Office Suite (Word, Excel, PowerPoint) and case management systems.
- Demonstrated experience with data analytics tools and software (e.g., SQL, Python, Tableau).
- Comprehensive knowledge of S. 409.913 and Chapter 817, Florida Statutes and federal and state laws and regulations pertaining to Medicare and Medicaid.
- Familiarity with Medicaid and Medicare Advantage programs, including claims processing and regulatory requirements.
- Strong analytical and problem-solving skills, with the ability to interpret complex data sets.
- Excellent written and verbal communication skills, including report writing and presentation capabilities.
- Detail-oriented, with strong organizational and time-management skills.
- Discretion in handling sensitive and confidential information.
- Knowledge of principles and practices of fraud analysis and prevention.
- Amenable to office-based or hybrid work environment, with travel as required to support meetings, investigations or training activities.
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Travel | | This position requires up to 50% travel. | | Physical Demands | | This position may require duties including lifting and carrying up to 20 pounds and sitting for prolonged periods of time. Good visual and auditory acuity as well as good manual dexterity and the ability to be readily understood are essential. | | Drug Free Workplace | | In compliance with the Drug-Free Workplace Act of 1988, Independent Living Systems (ILS) has a longstanding commitment to provide a safe, quality-oriented, and productive work environment. Alcohol and drug abuse pose a threat to the health and safety of ILS employees and to the security of the company's equipment and facilities. For these reasons, ILS is committed to the elimination of drug and alcohol use and abuse in the workplace. | | Affirmative Action/EEO Statement | | Independent Living Systems, LLC, and its subsidiaries, including Florida Community Care, provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, disability, ancestry, or any other characteristic protected by state, federal, or local law. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. |
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