Program Integrity Clinical Investigator (Location Flexible)

Competitive Compensation & Benefits Package!

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs
• Public Service Loan Forgiveness Qualifying Employer

Primary Purpose of Position: This position will assist in the development, implementation, revision, maintenance, and promotion of the agency’s fraud, waste, and abuse prevention and detection activities to ensure that the agency and the agency’s network operates in a manner that complies with applicable State and Federal laws, regulations, agency policies, national accreditation, and Medicaid guidelines. This position will perform functions relating to data analysis, investigations, and auditing relating to the monitoring, detection, and resolution of healthcare fraud, waste, and abuse.

Role and Responsibilities:

• Conduct, plan and perform independent and comprehensive audits, investigations and reviews (hereinafter referred to as investigations) into allegations of regulatory compliance violations, including fraud, waste, and abuse (FWA). Investigation includes the review of financial, consumer/clinical, provider, and/or other records, reports, and information necessary to thoroughly analyze and investigate suspected violations.
• Conduct clinical and non-clinical interviews, as necessary, to facilitate the investigative process. Work collaboratively with appropriate internal/external subject matter experts, agency and provider personnel, as necessary, to facilitate the investigative process.
• Conducts clinical chart reviews of instances of care authorized for utilization purposes, case reviews for individuals that are identified as either over or under-utilizers of services.
• Knowledge of documentation and clinical protocols for utilization purposes and case reviews for individual consumers in order to conduct clinical chart reviews.
• Clinical knowledge of managed systems of physical health services (professional and institutional), durable medical equipment, pharmacy, Mental Health, substance abuse, and Intellectual and Developmental Disabilities to also include co-occurring disorders. Knowledge of managed care practices and principles to detect fraud, waste and abuse.
• Clinical ability to recognize gaps in Partners Health Management service network and ability to communicate these identified gaps to appropriate parties.
• Serve as a Lead Investigator responsible for coordinating and leading agency investigative teams related to program integrity.
• Gather, evaluate, and synthesize evidence related to reported allegations to determine compliance with applicable state and federal policies, laws, and regulations.
• Prepare written and oral reports based on the results of assigned work that help to sustain findings and uphold disputed TNOs.
• Prepare timely, thorough, and accurate investigative reports; compile case file documentation; calculate overpayments; and synthesize findings in accordance with agency policies and procedures and departmental guidelines.
• Communicate effectively, both in writing and orally, to ensure accurate and timely completion of all assignments.
• Develop, implement, monitor, and maintain analytic reports to detect and prevent health care FWA.
• Conduct independent data mining and data analysis techniques utilizing claims data to detect abnormal claims and develop trends and patterns for potential cases.
• Independently prepare case documents for referral to the appropriate oversight agency and other external agencies involved in the prosecution of health care fraud.
• Manage cases from complaint intake through their ultimate conclusion, including supporting the case during all legal processes and appeals and the collection of final overpayments.
• Create, maintain, and manage cases within the case filing and tracking systems to ensure information is accurate, timely and complete.
• Consult with legal counsel in order to prepare testimony and other information necessary for appeals and as requested by external agencies investigating or prosecuting Medicaid fraud (as appropriate).
• Remain abreast of all federal and North Carolina rules and laws applicable to FWA and program integrity.
• Develop and conduct proactive audits, reviews and investigations of Partners’ programs to facilitate the detection and resolution of FWA.
• Develop, coordinate, and facilitate educational training to the Provider Network and agency personnel on issues relating to the compliance program, FWA.
• Identify information system edits/alerts/reports in need of implementation in the claims processing system(s).
• Recommend and implement compliance initiatives, policies, procedures, and practices designed to promote and encourage the reporting of suspected FWA without fear of retaliation.
• Serve on and/or facilitate various agency committees as deemed necessary by the Program Integrity Director
• Use data collection instruments and protocols previously developed or adopted by the department and develop data collection instruments as needed for complex investigations.
• Analyze computer-generated data sets, including claims data, to identify individuals and organizations that are most likely to provide evidence to ascertain whether FWA is likely to have occurred.
• Develop summary reports that illustrate data analysis to a nonscientific audience.
• Use appropriate software and systems to complete work assignments.
• Consult with IT to manage data and generate needed program reports.
• Perform other duties as assigned.

Knowledge, Skills and Abilities:

• Strong knowledge of state and federal laws, including those related to Medicaid FWA, and regulatory compliance are required.
• Knowledge of investigative methods and procedures.
• Knowledge of claims processing and clinical services.
• Excellent interpersonal and communication skills.
• Excellent analytical skills.
• Effective time management and organizational skills.
• Excellent conflict management skills.
• Proficient in Word, Excel, Outlook, and Power Point.
• Ability to learn and effectively manage various information systems including Partners’ claims reporting and North Carolina TRACKS.
• Ability to develop solutions and make recommendations for necessary process improvements.
• Ability to interpret contractual agreements, business oriented statistics, clinical/administrative services and records.
• A high level of integrity and discretion is required to effectively carry out the responsibilities related to this position.

Education and Experience Required: Master’s degree in a Human Services field, Health Administration, health informatics/analytics, or related field, or a Bachelor’s of Science in Nursing and licensed to practice as a Registered Nurse in North Carolina by the N. C. Board of Nursing. Minimum of 3 years recent experience in medical field with compliance monitoring, auditing or investigation experience. Licensed Clinical Social Worker, Licensed Clinical Addiction Specialist, Registered Nurse, Nurse Practitioner, Physician’s Assistant, or another clinical license related to the medical field.

Education and Experience Preferred: Five years recent experience in the medical field. Experience analyzing complex data, claims processing, utilization reviews, provider credentialing/monitoring, and/or fraud and abuse detection. Preferred credentials: Registered Health Information Technician (RHIT); Registered Health Information Administrator (RHIA); Certified Coding Specialist (CCS); Certified Fraud Examiner (CFE); and/or Accredited Healthcare Fraud Investigator (AHFI) certification.

Licensure/Certification Requirements: Current unrestricted LCSW, LPC, LPA, LMFT or LCAS licensure with the appropriate professional board of licensure in the state of North Carolina or licensed to practice as a Registered Nurse, Nurse Practitioner in North Carolina by the N. C. Board of Nursing or licensure in the State of North Carolina or licensed to practice as a Physician’s Assistant by the North Carolina Medical Board. Employee is responsible for complying with respective licensure board’s continuing education/ training requirements in order to maintain an active license. Must maintain licensure or certification.