Job Summary:
The Program Integrity Investigative Coordinator I monitors and maintains all SIU fraud reporting mechanisms (hotline, facets routing, fax, emails) to ensure compliance with regulatory requirements.
Essential Functions:
Accurately load Fraud, Waste & Abuse (FWA) referrals into the SIU Case Management System
Analyze FWA allegation facts and evaluate whether cases can be closed or escalated
Interview claimants, providers, members or any other individuals to obtain information relevant to any FWA investigation
Review claims for irregular billing patterns, consulting specialists when necessary
Generate various reports utilizing multiple fraud detection software systems
Conduct rudimentary data analysis to determine financial exposure or risk to FWA allegation across all lines of business
Responsible for maintaining anonymity and confidentiality during all phases of intake process
Independently identify billing errors and accidental overpayments initiating corrective action through the Research and Resolution Submission portal
Request medical records on an as-needed basis and as directed by Team Lead; partner with Clinical staff to resolve any issues
Assist Program Integrity in the oversight of Delegated Entities by routing state directed correspondence and generating claims data reports across all lines of business
Prepare and document Attestations, De-conflictions and Additional Allegation FWA informational letters, as contractually required, for any state Medicaid agency
Attend state Medicaid investigative meetings to transcribe updates provided by the Attorney General’s Office; update any applicable cases
Support compliance and regulatory requirements by verifying all state/federal directed provider removals are completed accurately across all lines of business
Drive accuracy of database information maintained in Case Management System; proactively verify the accuracy of provider information in concert with Facets and the Medicaid Information Technology System
Know and uphold the provisions of the Corporate Compliance Plan
Perform any other job related instructions as requested
Education and Experience:
High School Diploma or GED is required
Associate’s Degree in Health-Related Field, Law Enforcement, or Insurance is preferred
Minimum of three (3) years’ experience in a health care related field or Customer Service is required
Health care experience preferred (medical/dental claims, auditing, medical office experience, etc.)
Competencies, Knowledge and Skills:
Intermediate computer skills consisting of Microsoft Excel, Access, Outlook, Word, and Power Point
Ability to navigate multiple software systems at a high proficiency level
Good communication skills
Ability to work independently and within a team environment
High attention to detail
Critical listening and thinking skills
Proper grammar usage
Time management skills
Proper phone etiquette
Customer service oriented
Decision making/problem solving skills
Strong organization skills
Customer service oriented
Licensure and Certification:
Working Conditions:
Compensation Range:
$41,200.00 - $66,000.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
HourlyOrganization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
Brand=CareSource
CareSource is a healthcare organization that operates clinical systems and manages value-based reimbursement programs. The company utilizes Health Edge/Guiding Care application suites for clinical system configuration and operationalization. CareSource manages alternative payment models (APMs) and provider incentive programs across assigned markets, focusing on quality improvement and enhanced provider performance. The organization emphasizes cybersecurity, privacy, and technology services to protect organizational assets and ensure regulatory compliance.
