Healthcare Marketplace Senior Investigator (Full-time, Remote)

Integrity Management Services, Inc. (IntegrityM) is a woman-owned small business specializing in assisting government healthcare organizations prevent and detect fraud and abuse in their programs. At IntegrityM, we offer a culture of opportunity, recognition, and collaboration. We thrive off of these fundamental elements that make IntegrityM a great place to work. We offer the flexibility our employees need to challenge themselves and focus on advancing their professional development and careers. Large company perks. Small company feel.

In this role, the Marketplace Senior Investigator will provide investigative services to safeguard the integrity of the health insurance Marketplace authorized by the Affordable Care Act (ACA). The Marketplace Senior Investigator will use a variety of tools to initiate investigations, identify subjects and develop cases for future action, including a referral to law enforcement, education, over payment recovery and other administrative actions that follow the Marketplace rules, requirements and laws. The Marketplace Senior Investigator works independently as well as collaboratively with various team members and managers.

Job Responsibilities:

• Conducts background research of suspect agents/brokers to identify information regarding adverse business relationships, disqualifying violations, exclusions or licensing sanctions.

• Conducts data analysis to identify instances of suspected healthcare fraud, waste, and abuse.

• Identify data anomalies that lead to new project priorities.

• Reviews policies, regulations and instructions relevant to supporting suspected healthcare fraud, waste and abuse violations and provides that information as necessary in support of data analysis findings.

• Documents all findings relevant to support recommendations for further analysis or investigation referrals.

• Analyze and evaluate enrollment data related to consumer and Agent/Broker activity within the Marketplace.

• Collects and reviews records and documents relevant to investigation development.

• Conducts interviews and maintains accountability and safeguards any items considered to be of evidentiary value in accordance with established guidelines and rules of evidence.

• Coordinates investigations with appropriate federal and state law enforcement agencies, legal counsel and state and federal program administration agencies.

• Coordinates within a team of ACA policy subject matter experts (SMEs), data analysts, program managers, and other staff as appropriate to develop or unfound investigations.

• Inputs data into appropriate database tracking programs as needed in accordance with established rules.

• Coordinates with clients in support of findings and recommendations resulting from investigations and data analysis.

• Provides input into development of new fraud scheme studies.

• Actively supports preparation of comprehensive reports on the status of leads and investigations as required by CMS.

• Meets all established deadlines.

• Works with internal resources and external agencies to develop cases and corrective actions, as well as responds to requests for data and support.

• Maintains fraud case development quality standards so that proper case development is ensured and quality cases are fully prepared.

• Maintains proper and timely updates in appropriate tools and applications for their investigations. Case development databases and documents.

• Completes all requests for information from law enforcement within required timeframes.

• Enhances fraud detection and improves interdepartmental workflow so that it is evident the client is being proactive in its efforts to identify potentially fraudulent schemes.

• Conducts on-site visits and/or interviews as required for investigation.

• Performs ad hoc tasks/duties as assigned.

• Ensures compliance with all applicable privacy and security training requirements (both IntegrityM and external/client-based), whether on an annual or ad/hoc basis. Please note: certain position levels (leads, managers, directors or higher) may require additional “role-based” training to ensure compliance with applicable privacy and security requirements.

• Exercises appropriate discretion and independent judgment relating to company policies and practices in an effective, consistent and professional manner.

• Adheres to applicable policies ensuring commitment to quality, compliance and security to protect the confidentiality, integrity, and availability of sensitive data and information.

• Adheres to all IntegrityM and/or client privacy and security protocols governing sensitive and/or business confidential information.

Requirements

Job Qualifications:

• Bachelor degree (e.g., law enforcement investigation, statistics, data analysis) or equivalency in healthcare field that includes 2-4 years’ ACA and/or Medicare and Medicaid experience.
• 2 or more years’ experience with and/or understanding of ACA policies and regulations related to consumer enrollments requirements and Agent/Broker and Navigator responsibilities.
• Experience with FWA claims and investigations preferred.
• Strong investigative skills

• Strong communication and organization skills

• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases.

• Experience reviewing complex data reports.
• Strong oral and written communication skills, strong interpersonal skills, and superior organizational abilities.

· Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) a plus (and or may be required).

• Ability to take initiative, to maintain confidentiality, to meet deadlines, and to work in a team environment.
• Ability to report work activity on a timely basis.
• Ability to work independently and as a member of a team to deliver high quality work.
• Ability to multitask and prioritize assignments while meeting deadlines.

· Proficiency in Microsoft Office, specifically Microsoft Word and Excel.

· Passion and alignment with IntegrityM’s mission, vision, values and operating principles.

Additional Requirements:

· Must pass post hire background screening checks.

· For remote work, required to have wired and/or wireless internet access.

· Ability to obtain security clearance, if required by Client/Contract.