Job Summary:
The Team Lead, Program Integrity drives and encourages innovative investigative processes and workflows to reduce turnaround time and produce positive investigative outcomes.
Essential Functions:-
Direct the day-to-day activities and leadership of investigative staff to ensure goals of the department are met
- Serve as investigative planning consultant to investigative teams
- Assign cases to investigative staff
- Monitor and prioritize investigation allocation to maximize output and effectiveness of staff to ensure requirements and standards are achieved
- Identify knowledge gaps and provide training opportunities to direct reports
- Lead, arrange and conduct SIU staff meetings
- Coordinate the training of new and existing investigative staff to increase recognition of fraud and abuse indicators and properly direct workflows
- Mentor direct reports including, coaching, development, performance feedback, disciplinary issues, and annual performance evaluations
- Identify workflow and process inefficiencies
- Identify, recommend, develop, and implement internal departmental standard operating procedures
- Collaborate cross functionally between investigative teams and other matrix partners
- Proactively use analytic skills to identify potential areas of FWA and recommend future investigations
- Assist department leadership in identifying, planning, and implementing program integrity metrics and performance indicators
- Assist department leadership in identifying, planning, and implementing Artificial Intelligence (AI) agents and AI-enabled workflows
- Maintain knowledge and stay current on Health Care Fraud trends and schemes
- Recommend process or procedure changes and work with cross departmental teams on identified internal system gaps to mitigate FWA or financial risk
- Assist in response to state and federal regulatory audits
- Identify, assess and control risk to achieve compliance with state and federal integrity rules
- Perform investigative case work and contribute to case creation and lead generation
- Perform any other job related duties as requested.
Education and Experience:-
Bachelor's degree in Health-Related Field, Law Enforcement, or Insurance required
- Master's degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing) preferred
- Equivalent years of relevant work experience may be accepted in lieu of required education
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Five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics or related field required
- Supervisory or leadership experience preferred
Competencies, Knowledge and Skills:-
Intermediate proficiency in Microsoft Outlook, Word, Excel, Access, and Power Point
- Ability to formally present to a wide audience
- Ability to work independently and in a team environment with a high level of confidence
- Highest levels of ethics, integrity, ethics and professionalism in performance of all duties
- Excellent problem solving and decision-making skills with attention to details
- Demonstrated ability in research and drawing conclusions
- Ability to perform intermediate data analysis and to articulate understanding of findings
- Ability to work under limited supervision with moderate latitude for initiative and independent judgment
- Demonstrated leadership skills
- Self-motivated and self-directed
- Knowledge of government program compliance requirements – Medicare, Medicaid, Affordable Care Act (ACA), etc.
- Medical terminology, CPT, HCPCS, ICD codes or medical billing knowledge preferred
- Knowledge of medical insurance and/or state regulatory requirements
Licensure and Certification:-
One of the following certifications is required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) required
- Certified Professional Coder (CPC) preferred
- NHCAA or other fraud and abuse investigation training preferred
Working Conditions:-
General office environment; may be required to sit or stand for extended periods of time
- Flexible hours, including possible evenings and/or weekends as needed to serve the needs of our members and may refer members to other CareSource resources.
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Travel is not typically required
Compensation Range:
$72,200.00 - $115,500.00
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
#LI-SD1
Brand=CareSource
