Title: Certified Fraud Examiner/Program Integrity Analyst - REMOTE
Overview: Performs evaluation and development of leads, complaints, and/or investigations to verify allegations of potential appropriate administrative actions
Satisfactory completion of Background Check required
Job Summary
Seeking a full-time, remote, Program Integrity Analyst to assist with investigations and administrative actions relating to Medicare/Medicaid claims.
Essential Duties and Responsibilities
Perform evaluation and development of leads, complaints, and/or investigations to determine if further investigation and administrative actions are warranted
Conduct independent reviews resulting from the discovery of situations that potentially involve fraud or abuse
Utilize basic data analysis techniques to detect aberrancies in Medicare and Medicaid claims data, and proactively seeks out and develops leads/investigations received from a variety of sources (e.g., CMS, OIG, 1-800-MEDICARE, and fraud alerts)
Review 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 and Medicaid policies and initiate appropriate action
Make potential fraud determinations by utilizing a variety of sources such as internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid regulations, and the Social Security Act
Compile and maintain documentation and information related to investigations, cases, and/or leads
Participate in onsite audits in conjunction with investigation development
Develop and prepare potential Fraud Alerts and program vulnerabilities for submission to CMS. Share information on current fraud investigations with other Medicare contractors and state Medicaid agencies, law enforcement, and other applicable stakeholders
Prepare and submit external correspondence and reports, including, but not limited to, overpayment letters, fraud case referrals, suspensions, rebuttals, Medicare/Medicaid findings, reports, and administrative action recommendations
Submit suspension notifications to providers upon suspension approval
Prepare and submit ADR letters to providers associated with requests for medical record requests or suspension overpayment determinations
Serve as mentor/trainer to new Program Integrity staff
Perform other duties as assigned by PI Supervisor or PI Manager that contribute to task order goals and objectives
Competencies
Excellent research and organization, prioritization, and time management skills
Excellent verbal and written communication skills
Ability to work independently with minimal supervision
Ability to multi-task in a fast-paced environment
Knowledge of statistics, data analysis techniques, and PC skills are preferred
Education and Experience
High School Diploma or G.E.D equivalent; preference for completed college degree, technical degree related to the position (i.e. criminal justice, statistics, data analytics, etc.
At least 1 year of experience in Program Integrity investigations/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information and making appropriate decisions
Preference given to individuals that have attained a Certified Fraud Examiner (CFE) designation
Salary/Benefits
The salary range for this role is $68,000-$78,000 annually, commensurate with experience,
education, qualifications, certification, geographic location and business or organizational needs.
Benefits include Medical, Dental & Vision, Life, LTD and STD, 401(k) with company match and paid
time off.
About Us:
WCC is a small business specializing in benefit payment validations. In addition to supporting Federal Agencies with their workers compensation programs, WCC serves as a subcontractor to Prime contractors supporting the Centers for Medicare and Medicaid Services program integrity waste, fraud and abuse initiatives.
WCC is an Equal Opportunity Employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, caste, disability, veteran status, and other legally protected characteristics and maintain a drug-free workplace.