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CoventBridge Group · 2 days ago

Medicaid/Medicare Program Integrity Analyst II

United States

Full-time

Remote

Entry Level

$60K/yr - $70K/yr

1+ years exp

CoventBridge Group is the global leader in full-service investigations providing various services including fraud detection and compliance. The Medicaid/Medicare Program Integrity Analyst II will evaluate leads and complaints to verify potential fraud allegations and recommend administrative actions to improve healthcare delivery.

Customer ServiceOutsourcing

No H1B

Responsibilities

Perform evaluation and development of leads, complaints, and/or investigations to determine if further investigation and administrative actions are warranted

Conduct independent reviews resulting from the discovery of situations that potentially involve fraud or abuse

Utilize basic data analysis techniques to detect aberrancies in Medicare and Medicaid claims data, and proactively seeks out and develops leads/investigations received from a variety of sources (e.g., CMS, OIG, 1-800-MEDICARE, and fraud alerts)

Review information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare and Medicaid policies and initiate appropriate action

Make potential fraud determinations by utilizing a variety of sources such as internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid regulations, and the Social Security Act

Compile and maintain documentation and information related to investigations, cases, and/or leads

Participate in onsite audits in conjunction with investigation development

Develop and prepare potential Fraud Alerts and program vulnerabilities for submission to CMS. Share information on current fraud investigations with other Medicare contractors and state Medicaid agencies, law enforcement, and other applicable stakeholders

Prepare and submit external correspondence and reports, including, but not limited to, overpayment letters, fraud case referrals, suspensions, rebuttals, Medicare/Medicaid findings reports, and administrative action recommendations

Submit suspension notifications to providers upon suspension approval

Prepare and submit ADR letters to providers associated with requests for medical record requests or suspension overpayment determinations

Serve as mentor/trainer to new Program Integrity staff

Perform other duties as assigned by PI Supervisor or PI Manager that contribute to task order goals and objectives

Qualification

Data analysisFraud investigationCertified Fraud ExaminerResearch skillsStatistical knowledgeCommunication skillsTime managementOrganizational skills

Required

Excellent research and organization, prioritization, and time management skills

Excellent verbal and written communication skills

Ability to work independently with minimal supervision

Ability to multi-task in a fast-paced environment

High School Diploma or G.E.D. equivalent, with preference given to those candidates who have successfully completed college or technical degree programs related to the position (e.g., Criminal Justice, Statistics, Data Analysis, etc.)

At least 1 year of experience in Program Integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions