Job Summary:

The Program Integrity Controls Analyst III is responsible for complex Program Integrity requirement for all product lines in all states to ensure delivery on commitments.

Essential Functions:

• Lead SIU implementation of Program Integrity Medicaid/Medicare legal, regulatory and contract requirements with little direction
• Develop and document all required state and federal monthly, quarterly and annual reports
• Monitor and audit Grievance and Appeals and Prior Authorizations for fraud trends/patterns and under- and overutilization of benefits
• Establish, control, evaluate and revise FWA detection, deterrent and prevention policies and procedures/processes; ensure compliance with all state and federal requirements
• Draft responses to all required state and federal audits, questionnaires, surveys and other inquires
• Draft responses to state and federal Readiness Review Tools (RRTs) and Requests for Proposals
• Calculate financial impact for SIU Investigative Corrective Actions
• Draft and submit responses to SIU Management surveys
• Lead implementation of new compliance/legal requirements
• Represent SIU on key external and internal committees
• Assist in training SIU department personnel on SIU policies, procedures and processes and implementation status
• Write and present reports and participate in department level projects
• Attend any training required by state and federal agencies about Program Integrity compliance
• Initiate and maintain network and outreach activities to ensure best practices in SIU functions
• Oversee the member/provider recovery account receivable process
• Prepare, update and/or contribute to all FWA prevention and reporting materials including Provider Manuals, Member Handbooks, Employee Handbook, Member/Provider Newsletters, website pages, check flyers, reporting forms, FWA E-Learning, FWA reporting mechanisms, FWA Policies and Procedures ,etc.
• Update, prepare, distribute and collect attestations for FWA informational letters to Delegated Entities
• Capture and draft report of required EOB data to state and federal agencies
• Create and maintain detail, audit-ready, and product specific documentation for all FWA requirements
• Capture SIU management statistics and prepares report for department management monthly
• Attend FWA and/or compliance seminars annually to stay current on Program Integrity issues
• Establish and maintain collaborative working relationships with state, federal and other managed care Medicaid/Medicare Program Integrity functions
• Support NCQA and URAC Program Integrity accreditation initiatives to include any policy, procedure and process changes required and educating SIU staff on requirements
• Know and uphold the provision of the Corporate Compliance Plan
• Maintain confidentiality of all SIU investigative case information
• Present FWA overview and employee responsibilities at each new hire training class
• Perform any other job related instructions as requested

Education and Experience:

• Bachelor’s Degree in Compliance, Healthcare or a Legal field or equivalent years of relevant work experience is required
• Minimum of four (4) years of experience in a compliance or legal field is required
• Previous experience in internal and external auditing, risk management and performance improvement is required
• Previous experience in financial calculations is required
• Experience with Marketplace, Medicaid and/or Medicare products is strongly preferred

Competencies, Knowledge and Skills:

• Advanced level of proficiency with Microsoft Office Suite
• Strong written and oral presentation skills
• High level of integrity and ethics
• High level communication skills both verbal and written
• Ability to work independently and collaboratively within a team environment
• High attention to detail
• Familiarity with the healthcare field
• Critical listening and thinking skills
• Skill in negotiating issues and resolving problems
• Leadership experience and ability required
• Strong decision making/problem solving ability
• Ability to manage multiple projects and deadlines

Licensure and Certification:

• Fraud or Compliance designation/certification is required

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource 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):

Organization Level Competencies

• Create an Inclusive Environment

• 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 inclusive environment that welcomes and supports individuals of all backgrounds.