The Clinical Investigator monitors service delivery for program integrity through fraud and abuse investigations and audits, including review of claims data, clinical records and reference materials, investigative interviewing, provider education and technical assistance, and monitoring implementation of provider corrective actions.
Requirements
- Conduct Audit/Investigations and prepare reports
- Review allegation(s), conduct preliminary investigation and make disposition recommendations using independent judgment
- Develop audit/investigation plans and tools based upon alleged non-compliance and data analytics
- Systematically and accurately collect, document, and store evidence
- Conduct post-payment audits of Medicaid and State funded providers to ensure that services are rendered in accordance with established state and federal rules, regulations, policies, and terms of provider contractual agreements with the state
- Identify inappropriate billing and overpayments
- Utilize clinical knowledge and experience to determine if documented services were clinically appropriate and/or medically necessary
- Conduct interviews with provider employees, former employees, recipients of services, and other witnesses
- Document allegations, investigative activities, and findings in a detailed audit/investigation report
- Work with the Special Investigations Supervisor and Investigative Team to support investigative activities
- Assure that individuals served do not pay for health services inappropriately
- Track allegations of fraud, waste, and abuse in a case management system from referral to final disposition
- Consult with the Corporate Compliance Unit when potential internal compliance issues are identified
- Consult on cases
- Provide clinical guidance to non-clinical staff on documentation obtained from providers
- Provide guidance to non-clinical staff on Medicaid Clinical Coverage Policies and State Service Definitions and by participating in ad hoc meetings related to clinical regulatory matters
- Participate in ad hoc meetings related to clinical matters
- Conduct Regulatory Review/ Research
- Diligently research clinical policies, administrative code, federal/state laws in order to assess for non-compliance
- Analyze data
- Analyze data from a variety of sources, including but not limited to claims, authorizations, credentialing/enrollment, grievances, prior audits/investigations, incarceration records, incident reports, policies/procedures, to inform decision making
- Utilize various MicroStrategy reports data during the investigation process
- Analyze claims data to determine if an allegation is supported
- Analyze claims data during investigations to determine if there are indicators of fraud/abuse other than the allegation received
- Identify other data sources to review during investigations based on the allegation(s)
- Provide Case reports/presentations to internal and external stakeholders
- Present audit/investigation findings and make disposition recommendations using independent judgment to the Chief Compliance and Risk Officer, Senior Director of Program Integrity, Special Investigations Supervisor, and Alliance Compliance Committee
- Present case status updates in individual supervision sessions, unit team meetings, Division meetings (as designated by supervisor), and to NC Department of Justice (as requested)
- Conduct and participate in Investigation Planning meetings with the Investigation Team
- Interpret and convey highly technical information to others
- Provide Technical Assistance/Education
- Educate providers on the errors identified in the audit and investigation process
- Recognize when providers can improve through technical assistance (TA) rather than full investigation when FWA is not evident and/or pervasive
- Recognize quality of care issues in order to make recommendations to appropriate entities/authorities
- Monitor Provider Action and Follow-Up
- Document Improper Payment Charts, Statements of Deficiency, provides feedback and technical assistance to providers as needed/requested, and follows up on provider corrective action through the probation process, as applicable
- Prepare for and participate in provider appeal process and/or court hearings to explain and defend audit/investigation findings
- Recommend policy, procedure, or process changes
Benefits
- Medical
- Dental
- Vision
- Life
- Long Term Disability
- Generous retirement savings plan
- Flexible work schedules including hybrid/remote options
- Paid time off including vacation, sick leave, holiday, management leave
- Dress flexibility
