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Reviews incoming leads to determine if further investigation is warranted.
Conducts independent reviews resulting from the discovery of situations that potentially involve fraud, waste, or abuse.
Utilizes basic data analysis techniques to detect aberrancies in Medicare claims data
Completes written referrals to their supervisor as needed on potential investigations derived from complaint reviews.
Reviews information contained in the Medicare 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 including Medicare coverage and reimbursement guidelines, as well as Medicare law and regulations.
Compiles and maintains various documentation and other reporting requirements.
Performs other duties as assigned to meet Medicare fraud and abuse goals and objectives.
Qualifications for Program Integrity Analyst
Education At a minimum, a high school diploma, with preference given to those candidates who have successfully completed college or technical degree programs related to the position (e.g. criminal justice, statistics, data analysis, etc.)
Preference will also be given to those individuals that have attained the Certified Fraud Examiners (CFE) designation.
Must have and maintain a valid driver's license issued by the state of residence
Abilities (SKA) Excellent oral, written and verbal skills.
Ability to work independently with minimal supervision.
Knowledge of statistics, healthcare investigation, data analysis techniques, and PC skills are preferred.
Experience Preference is 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, but not required.
Must have and maintain a valid driver's license issued by the state of residence.
Commensurate with experience