Program Integrity Controls Analyst III (Certification Required)

Job Summary:

The Program Integrity Controls Analyst III is responsible for complex Program Integrity requirement for all product lines in all states to ensure delivery on commitments.

Essential Functions:

• Lead SIU implementation of Program Integrity Medicaid/Medicare legal, regulatory and contract requirements with little direction
• Develop and document all required state and federal monthly, quarterly and annual reports
• Monitor and audit Grievance and Appeals and Prior Authorizations for fraud trends/patterns and under- and overutilization of benefits
• Establish, control, evaluate and revise FWA detection, deterrent and prevention policies and procedures/processes; ensure compliance with all state and federal requirements
• Draft responses to all required state and federal audits, questionnaires, surveys and other inquires
• Draft responses to state and federal Readiness Review Tools (RRTs) and Requests for Proposals
• Calculate financial impact for SIU Investigative Corrective Actions
• Draft and submit responses to SIU Management surveys
• Lead implementation of new compliance/legal requirements
• Represent SIU on key external and internal committees
• Assist in training SIU department personnel on SIU policies, procedures and processes and implementation status
• Write and present reports and participate in department level projects
• Attend any training required by state and federal agencies about Program Integrity compliance
• Initiate and maintain network and outreach activities to ensure best practices in SIU functions
• Oversee the member/provider recovery account receivable process
• Prepare, update and/or contribute to all FWA prevention and reporting materials including Provider Manuals, Member Handbooks, Employee Handbook, Member/Provider Newsletters, website pages, check flyers, reporting forms, FWA E-Learning, FWA reporting mechanisms, FWA Policies and Procedures ,etc.
• Update, prepare, distribute and collect attestations for FWA informational letters to Delegated Entities
• Capture and draft report of required EOB data to state and federal agencies
• Create and maintain detail, audit-ready, and product specific documentation for all FWA requirements
• Capture SIU management statistics and prepares report for department management monthly
• Attend FWA and/or compliance seminars annually to stay current on Program Integrity issues
• Establish and maintain collaborative working relationships with state, federal and other managed care Medicaid/Medicare Program Integrity functions
• Support NCQA and URAC Program Integrity accreditation initiatives to include any policy, procedure and process changes required and educating SIU staff on requirements
• Know and uphold the provision of the Corporate Compliance Plan
• Maintain confidentiality of all SIU investigative case information
• Present FWA overview and employee responsibilities at each new hire training class
• Perform any other job related instructions as requested

Education and Experience:

• Bachelor’s Degree in Compliance, Healthcare or a Legal field or equivalent years of relevant work experience is required
• Minimum of four (4) years of experience in a compliance or legal field is required
• Previous experience in internal and external auditing, risk management and performance improvement is required
• Previous experience in financial calculations is required
• Experience with  Marketplace, Medicaid and/or Medicare products is strongly preferred

Competencies, Knowledge and Skills:

• Advanced  level of proficiency with Microsoft Office Suite
• Strong written and oral presentation skills
• High level of integrity and ethics
• High level communication skills both verbal and written
• Ability to work independently and collaboratively within a team environment
• High attention to detail
• Familiarity with the healthcare field
• Critical listening and thinking skills
• Skill in negotiating issues and resolving problems
• Leadership experience and ability required
• Strong decision making/problem solving ability
• Ability to manage multiple projects and deadlines

Licensure and Certification:

• Fraud or Compliance designation/certification is required

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business