Job Description

Job Description Summary: 

The Program Integrity (PI) Analyst performs in-depth evaluation and analysis of potential fraud cases and requests for information using claims information and other sources of data. Supports the development of complex cases that involve high dollar amounts, sensitive issues, or that otherwise meet criteria for referral to law enforcement, recoupment of overpayment, and/or administrative action based on reactive and proactive data analysis. 

Duties/Responsibilities:   

• Conducts independent investigations resulting from the discovery of situations that are suspected to involve fraud, waste, or abuse. Utilizes data analysis techniques to detect aberrancies in Medicare and Medicaid claims data, and proactively seeks out and develops leads received from a variety of sources (e.g., CMS, OIG, fraud alerts). 

• Completes written referrals to law enforcement and takes steps to initiate recoupment of overpaid monies. 

• Refer suspected instances of apparent unethical or improper practices or unprofessional conduct (e.g., quality of care issues) to the appropriate entity. For Medicaid-related issues, shall coordinate with the State Program Integrity Unit and any other entities at state request within the state responsible for ethical, professional or quality of care issues. For Medicare- related issues, the UPIC shall coordinate with the Quality Improvement Organization (QIO). For issues involving both programs, the UPIC shall coordinate across these entities. 

• Responds to requests for information from law enforcement. Maintains cases that were referred to law enforcement. 

• Reviews 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 policies and initiates appropriate action. 

• Makes potential fraud determinations by utilizing a variety of sources such as the UPIC's internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid regulations, and the Social Security Act. 

• Develops and prepares potential Fraud Alerts and Program Vulnerabilities for submission to CMS; shares information on current fraud investigations with other Medicare contractors, law enforcement, and other applicable stakeholders. 

• Reviews and responds to requests for information from Medicare and Medicaid stakeholders as assigned; pursues applicable administrative actions during investigation/case development (e.g., payment suspensions, civil monetary penalties, requests for exclusion, etc.) 

• Participates in onsite audits in conjunction with investigation development. Provides support of cases at hearing/appeal and ALJ level. Maintains chain of custody on all documents and follows all confidentiality and security guidelines. 

• Compiles and maintains various documentation and other reporting requirements.  

• Performs other duties as assigned by PI Management that contribute to UPIC goals and objectives. 

• Maintains electronic files and all associated notes and documentation in multiple systems while adhering to strict deadlines. 

• Other duties as assigned

Minimum required qualifications/skills: 

• High School diploma 

• Excellent oral, written and verbal skills with experience compiling data and writing reports  

• Ability to work independently with minimal supervision in a fast-paced environment with strict deadlines 

• At least 1 year of experience in program integrity and healthcare fraud investigation/detection that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions

Preferred qualifications/skills: 

• Successful completion of a college or technical degree program related to the position (e.g. criminal justice, statistics, data analysis, etc.) 

• Certified Fraud Examiners (CFE) designation 

• Experience with fraud detection and investigation within Medicaid and/or Medicare program. 

• Knowledge of statistics, data analysis techniques, and PC skills are preferred.

Supervisory Responsibilities: 

• None

Location:  

• Working from an office in Grove City, OH or, 

• A work from home position may be considered for the right candidate, if living in the states of Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, Kentucky, Iowa, Missouri, Nebraska and Kansas.

Office Equipment (if a WFH position): 

• A locking cabinet and/or desk appropriate for storing documents and electronic media  

• A cross-cut or micro-cut (preferred) shredder 

• A broadband internet connection with minimum download speed of 15MB - 20MB. (Wireless Air Cards are not approved for work from home use. Free/public wi-fi connections not approved.) 

• Telework office connection can be hard-wired direct or Wi-Fi connection. Minimum of WPA2 (Wi-Fi Protected Access II); prefer WPA2 + AES. (WPA and WPE are not approved.) Recommended home wireless standards: Wireless G – Goes through walls, but Medium speed. (Use if router not visible); Wireless N - Great for Speed, but not effective through walls. (Use if router visible); Wireless AC - High speed, but not effective through walls or distance. (Use if router visible) 

• Separate phone line (can be a cell phone) 

• Office equipment (such as laptop and printer will be provided)

Physical Requirements: 

• May require prolonged periods of sitting at a desk.

Other: 

• Must have and maintain a valid driver's license issued by the state of residence 

• Successful candidates will be required to consent to background checks, credit check and other contract related screenings. 

• Travel may be required, and all travel expenses, if applicable, are reimbursable via GSA standards.

Company Description

Accomplished federal contractor specializing in fighting fraud, waste, and abuse in government entitlement programs.