Job Summary:

The Incident Management Investigator conducts clinical case investigations related to incidents submitted to the incident management system.

Essential Functions:

• Investigation includes interviewing member, claimant (if claimant is not the member), personal caregivers, facility staff and others
• Contacts providers & their employees, business partners and representatives from regulatory agencies and law enforcement in the conduction of investigations,
• Develops member care plan including member and caregiver education and corrective action plans
• Collaborates with internal departments including, but not limited to, Care Management, SIU, Pharmacy, Medical Management, Provider Relations, Claims, Internal Audit, Regulatory, and Legal
• Develops and maintains contacts/liaison with business partners, law enforcement, regulatory agencies, state, other company staff and external contacts involved in fraud investigation, detection and prevention
• Proactively uses analytical skills to identify all potential areas of member concern including fraud, waste and abuse
• Responsible for assisting department in meeting all state, regulatory and departmental deadlines
• Recommends and participates in development and implementation of internal departmental policies and procedures
• Performs any other job related duties as requested.

Education and Experience:

• Associates degree required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Two (2) years of experience in healthcare operations, care coordination, escalation or management required

Competencies, Knowledge and Skills:

• Intermediate proficiency level with Microsoft Outlook, Word, Excel, Power Point, and Access is required
• Effective oral and written communication skills
• Ability to perform thorough investigations, develop care plans and see case through resolution and closure; ability to maintain confidentiality
• Ability to organize and prioritize daily workload & meet required deadlines
• Ability to work independently and as a member of a team to deliver high quality work
• Presentation skills necessary
• Knowledge of Medicaid and Medicare, preferred
• Knowledge of medical terminology, medical diagnostic, procedural terms, and instances of FWA
• Critical listening and thinking skills

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Travel is not typically required

Compensation Range:

$62,700.00 - $100,400.00

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):

Salary

Organization 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.

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