Position: Program Integrity Specialist

Category: Non-Exempt

Location: Hybrid Position - May require some onsite time, but will also have some remote flexibility

Salary Range: $45,231 - $56,487

Closing Date: Until Filled

Position Number: 17-40-2049

Primary Purpose of Position: This position is responsible for monitoring and investigating the community of network providers’ program integrity activities which bill Medicaid, state, and local funds. Program Integrity functions are to promote integrity in all Behavioral Health (BH) and Intellectual/Developmental Disabilities (I/DD) Tailored Plan activities and combat fraud, waste, and abuse of benefits, program funds and misuse of the systems that support Medicaid Managed Care and State-funded Services. This position helps to guard against external (members, providers, subcontractors, or others) fraud, waste, or abuse of benefits, program funds and misuse of the systems that support Medicaid Managed Care and State-funded Services.

This position is responsible for the assessment of services provided and billed and includes activities including but not limited to, review of provider billings to detect possible fraud, waste and abuse as set forth by the BH/I/DD, NC Department of Health and Human Services, regulatory agencies, and applicable accrediting agencies. This position will conduct prepayment and post-payment reviews of contracted providers to prevent and detect fraud, waste, and abuse. The employee will develop investigation reports, identify overpayments, and make recommendations as identified with investigations.

Responsibilities and Duties:

• Review healthcare procedure claims billed to determine if provider payments were rendered in accordance with rules, regulations, service definition, service utilization, and contractual requirements.
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud.
• Propose new Fraud Prevention edits to automated claims/billing system when new fraudulent schemes are discovered
• Perform investigative practices such as conduct on-site inspections, interview providers and members, and review medical records to verify compliance with program policies and/or standards of health care, appropriateness of services or medical necessity.
• Litigation testimony as applicable.
• Work in conjunction with various regulatory bodies to include but not limited to DHB, OCPI, and MIU.
• Prepare reports and exhibits from the findings of provider reviews or investigations and develop recommendations or intervention strategies to correct or prevent abusive practices, including proposals to recover inappropriately paid monies or to suspend or terminate program participation.
• Develop methods to detect and prevent fraud.
• Perform auditing work with responsibility for examining and analyzing financial functions, program operations and systems to determine compliance with financial and program procedures and regulations.
• Ability to review and analyze claims/payment data, financial and administrative data.
• Compile, monitor, and audit various financial, systems and/or program information for accuracy, integrity, and conformance to rules and regulations.
• Identify substantive issues that require research and data analysis.
• Implement corrective action plans
• Participate in annual provider fraud, waste, and abuse trainings to internal staff, external providers, etc.
• Other duties as required

Education/Experience/Licensure: Bachelor’s degree in compliance, analytics, government/public administration, auditing, security management or pre-law and must have at least 3 years of experience in healthcare compliance, regulatory analysis, policy development, auditing, investigations, accreditation or any equivalent combination of related training and experience.

Credentials such as Certified Fraud Examiner, Accredited Healthcare Fraud Investigator, Certified Insurance Fraud Investigator, Certified Public Accountant, Certified Internal Auditor, Certified Compliance Professional, CLEAR certification, or other similar licensure/certification is preferred.

Excellent Benefit Package to Include:

• Employer paid Health, Dental, Life and Long Term Disability Insurance
• NC Local Government Retirement
• NC 401K with 4% employer match
• 12 paid holidays per year
• Monthly sick and vacation leave accruals