Program Integrity Controls Analyst II (Compliance Experience required)

Job Summary:

The Program Integrity (PI) Controls Analyst II is responsible for compliance and oversight of fraud, waste, abuse, Program Integrity-related requirements, and for management of our fraud risk framework for all product lines in all states to ensure delivery on commitments.

Essential Functions:

• Support SIU implementation of Program Integrity Medicaid/Medicare/Marketplace legal, regulatory and contract requirements
• Provide quality assurance monitoring for all PI required state and federal monthly, quarterly, ad hoc and annual reports
• Work with PI functional areas to develop risk mitigation strategies and change implementation plans based on risk assessment processes
• Ability to attend conferences, outreach to organizations such as the Health Care Compliance Association (HCCA), other managed care plans to identify best in industry PI practices
• Monitor program integrity solutions put in place for ongoing compliance and for continuous improvement opportunities
• Support the development, evaluation and revision of FWA detection, deterrent and prevention policies and procedures/processes; ensure compliance with all state and federal requirements
• Support drafting of responses to all required state and federal audits, questionnaires, surveys and other inquires
• Support drafting of responses to state and federal Readiness Review Tools (RRTs) and Requests for Proposals
• Collaborate interdepartmentally to develop and implement PI cross-functional policies, procedures and process flows
• Assist with the development of the Program Integrity risk assessment and work plan
• Work on implementation of new compliance/legal requirements
• Represent SIU on key external and internal committees
• Assist in training SIU department personnel on SIU policies, procedures and processes and implementation status
• Write and present reports and participate in department level projects
• Attend any training required by state and federal agencies about Program Integrity compliance
• Initiate and maintain network and outreach activities to ensure best practices in SIU functions
• Prepare, update and/or contribute to all FWA prevention and reporting materials including Provider Manuals, Member Handbooks, Employee Handbook, Member/Provider Newsletters, website pages, check flyers, reporting forms, FWA E-Learning, FWA reporting mechanisms, FWA Policies and Procedures ,etc.
• Support vendor/delegate oversight and monitoring for compliance of PI-related functions
• Create and maintain detail, audit-ready, and product specific documentation for all FWA requirements
• Attend FWA and/or compliance seminars annually to stay current on Program Integrity issues/ emerging risks
• Establish and maintain collaborative working relationships with state, federal and other managed care Medicaid/Medicare/Marketplace Program Integrity functions
• Support NCQA and URAC Program Integrity accreditation initiatives to include any policy, procedure and process changes required and educating SIU staff on requirements
• Know and uphold the provision of the Corporate Compliance Plan
• Maintain confidentiality of all SIU investigative case information
• Monitor PI inbox for incoming inquiries and ensure timely, accurate responses
• Provides cross-training of team members
• Perform any other job-related instructions as requested

Education and Experience:

• Bachelor’s Degree in Compliance, Healthcare or a Legal field or equivalent years of relevant work experience is required
• Minimum of two (2) years of experience in a compliance or legal field is required
• Previous experience in internal and external auditing, risk management and performance improvement are preferred
• Experience with Marketplace, Medicaid and/or Medicare products is strongly preferred

Competencies, Knowledge and Skills:

• Solid level of proficiency with Microsoft Office Suite
• Solid data analytics and reporting capabilities
• Strong written and oral presentation skills
• High level of integrity and ethics
• High level communication skills both verbal and written
• Ability to work independently and collaboratively within a team environment
• Understanding of control framework(s) used to manage an effective PI plan and PI vendor/delegate oversight
• High attention to detail
• Familiarity with the healthcare field
• Critical listening and thinking skills
• Skill in negotiating issues and resolving problems
• Strong decision making/problem solving ability
• Ability to manage multiple projects and deadlines

Licensure and Certification:

• Fraud or Compliance designation/certification is preferred

Working Conditions:

• Most work will be performed in an office or virtual setting; however, performing onsite audits may also be necessary depending on assignments
• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

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):

Organization Level Competencies

• Create an Inclusive Environment

• 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 inclusive environment that welcomes and supports individuals of all backgrounds.