• Medicare/Medicaid Fraud Investigator

    Job ID 2018-2955
    Job Locations
    US-Remote | US-IL-Lisle | US-MI-Bingham Farms | US-OH-Grove City
    Category
    Healthcare / Biotechnology
    Type
    Regular Full-Time
  • Overview

    NCI is a leading provider of enterprise solutions and services to U.S. defense, intelligence, health and civilian government agencies. Coupled with a refined focus on strategic partnerships, we are successfully bridging the gap between commercial best practices and mission-critical government processes. Core competencies include:

    • Artificial intelligence
    • Agile digital transformation
    • Advanced analytics
    • Hyperconverged infrastructure solutions
    • Cyber security and information assurance
    • Fraud, waste and abuse
    • Engineering and logistics

    MF18

    NCI has been designated a 2018 Military Friendly Employer by MilitaryFriendly.com 

     

    Headquartered in Reston, Virginia, NCI has approximately 2,000 employees operating at more than 100 locations worldwide.

    Responsibilities

    NCI: As the Medicare Fraud Investigator (Program Integrity Analyst II) at AdvanceMed, you will be part of investigations involving potential Medicare and Medicaid fraud and abuse.  In assuming this position, you will be a critical contributor to meeting NCI AdvanceMed's mission: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse.  

     

    PROGRAM INTEGRITY ANALYST II 

    • Performs comprehensive claims reviews to make payment determinations based on Medicare coverage, coding, and utilization of services and practice guidelines
    • Utilizes electronic health information imaging and medical review decisions by electronic database module
    • Utilizes internet and intranet sources for policy verification
    • Utilizes Microsoft Office and other software templates as associated source input for claims review
    • Conducts independent investigations resulting from the discovery of situations that potentially involve fraud or abuse
    • Utilizes data analysis techniques to detect aberrancies in claims data, and proactively seeks out and develops leads received from a variety of sources (e.g., CMS, OIG, fraud alerts)
    • 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 abuse billing practices or vulnerabilities in Medicare policies and initiates appropriate action
    • Completes written referrals to law enforcement and takes steps to recoup overpaid monies
    • Makes potential fraud determinations by utilizing a variety of sources such as the task order’s internal guidelines, Medicare provider manuals, Medicare 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 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
    • Communicates internally with all levels of the task order and externally with law enforcement, beneficiaries and the medical community
    • Performs other duties as assigned by management that contribute to task order goals and objectives

    Qualifications

    MINIMUM REQUIREMENTS:

    • High School Diploma or equivalent related experience
    • Must have a valid driver’s license issued by the state of residence
    • Ability to work independently with minimal supervision
    • Experience working with proper claims handling, process and procedures
    • Experience working with business processes and re-engineering
    • Experience working with the implementation of company value propositions

     

    EXPERIENCE REQUIRED BY LEVEL:

    • 1 – 6 Years

     

    PREFERRED EDUCATION AND EXPERIENCE:

    • Associate’s or Bachelor’s Degree or equivalent related experience
    • Preference will be given to those candidates who’ve completed Certified Fraud Examiners (CFE) certification
    • Preference will be given to those candidates with experience in fraud detection and investigation within the Medicare program
    • Previous law enforcement experience, especially in the field of investigations is a plus

     

    PHYSICAL REQUIREMENTS:

     

    This position requires the ability to perform the below essential functions:

    • Sitting for long periods
    • Ambulate throughout an office
    • Ambulate between several buildings
    • Travel by land or air transportation 25%

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