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Alliance Health · 1 day ago

Clinical Investigator (Full-Time Remote, Mecklenburg County, North Carolina Based)

United States

Full-time

Remote

Mid, Senior Level

$78K/yr - $99K/yr

5+ years exp

Alliance Health is a healthcare organization seeking a Clinical Investigator to monitor service delivery for program integrity through fraud and abuse investigations and audits. The role involves conducting audits, analyzing data, and providing technical assistance to ensure compliance with regulations and policies.

Health Care

Responsibilities

Review allegation(s), conduct preliminary investigation and make disposition recommendations using independent judgment

Develop audit/investigation plans and tools based upon alleged non-compliance and data analytics

Request and/or collect medical records, personnel records, policies/procedures, compliance plans, and other documents from providers based on audit/investigation plans

Systematically and accurately collect, document, and store evidence

Conduct post-payment audits of Medicaid and State funded providers to ensure that services are rendered in accordance with established state and federal rules, regulations, policies, and terms of provider contractual agreements with the state

Identify inappropriate billing and overpayments

Utilize clinical knowledge and experience to determine if documented services were clinically appropriate and/or medically necessary

Conduct interviews with provider employees, former employees, recipients of services, and other witnesses

Document allegations, investigative activities, and findings in a detailed audit/investigation report

Work with the Special Investigations Supervisor and Investigative Team to support investigative activities

Assure that individuals served do not pay for health services inappropriately

Track allegations of fraud, waste, and abuse in a case management system from referral to final disposition

Consult with the Corporate Compliance Unit when potential internal compliance issues are identified

Provide clinical guidance to non-clinical staff on documentation obtained from providers

Provide guidance to non-clinical staff on Medicaid Clinical Coverage Policies and State Service Definitions and by participating in ad hoc meetings related to clinical regulatory matters

Participate in ad hoc meetings related to clinical matters

Diligently research clinical policies, administrative code, federal/state laws in order to assess for non-compliance

Analyze data from a variety of sources, including but not limited to claims, authorizations, credentialing/enrollment, grievances, prior audits/investigations, incarceration records, incident reports, policies/procedures, to inform decision making

Utilize various MicroStrategy reports data during the investigation process

Analyze claims data to determine if an allegation is supported

Analyze claims data during investigations to determine if there are indicators of fraud/abuse other than the allegation received

Identify other data sources to review during investigations based on the allegation(s)

Present audit/investigation findings and make disposition recommendations using independent judgment to the Chief Compliance and Risk Officer, Senior Director of Program Integrity, Special Investigations Supervisor, and Alliance Compliance Committee

Present case status updates in individual supervision sessions, unit team meetings, Division meetings (as designated by supervisor), and to NC Department of Justice (as requested)

Conduct and participate in Investigation Planning meetings with the Investigation Team

Interpret and convey highly technical information to others

Educate providers on the errors identified in the audit and investigation process

Recognize when providers can improve through technical assistance (TA) rather than full investigation when FWA is not evident and/or pervasive

Recognize quality of care issues in order to make recommendations to appropriate entities/authorities

Document Improper Payment Charts, Statements of Deficiency, provides feedback and technical assistance to providers as needed/requested, and follows up on provider corrective action through the probation process, as applicable

Prepare for and participate in provider appeal process and/or court hearings to explain and defend audit/investigation findings

Recommends revisions to Alliance Health procedures and policies

Qualification

Registered Nurse (RN)Health care complianceMedicaid/Medicare knowledgeInvestigative methodsData analysisMicrosoft OfficeAnalytical skillsCommunication skillsTime managementProblem-solving

Required

Graduation from an accredited school of Nursing with a Registered Nurse (RN) license and five (5) years relevant post-graduate experience

OR Master's degree in human services/social sciences, health care compliance, analytics, government/public administration, auditing, security management, criminal justice, or pre-law and Five (5) years relevant post-graduate experience

Special Requirement- Current, unencumbered clinical license as an LCSW, LCMHC, LMFT, LCAS, LPA or RN

Knowledge of Health care industry and/or Medicare/Medicaid/Behavioral Health

Knowledge of the state and federal Medicaid laws, state and federal criminal and civil fraud laws, regulations, policies, rules, guidelines, service limitations, and various Medicaid programs

Knowledge and proficiency in claims adjudication standards & procedures

Knowledge of investigative methods and procedures

High degree of integrity and confidentiality required handling information that is considered personal and confidential

Skill in using Microsoft Office products (such as Word, Excel, Outlook, etc.)

Analytical skills and ability to make deductions; logical and sequential thinker

Strong verbal and written communication skills. Ability to write clear, accurate and concise rationale in support of findings

Ability to manage time, prioritize work, and use problem-solving approaches

Ability to interpret contractual agreements, business-oriented statistics medical/administrative services and records

Ability to identify resources, gather evidence, analyze raw data and generate reports

A general understanding of all major managed care functions in particular as it relates to prior authorization, utilization reviews, grievance management, provider credentialing and monitoring

Knowledge of the Alliance Health service benefit plans and network providers