Team Lead, Program Integrity (Triage) at CareSource Management Services LLC — Remote

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
• 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.
• Travel is not typically required

Compensation Range:

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

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Brand=CareSource