Clinical Field Investigator II

Job Summary:

The Clinical Field Investigator II conducts clinical case investigations related to incidents submitted to the incident management system.  

Essential Functions:

• Investigation includes interviewing member, claimant (if claimant is not the member), personal caregivers, facility staff and others
• Contacts providers & their employees, business partners and representatives from regulatory agencies and law enforcement in the conduction of investigations,  
• Develops member care plan including member and caregiver education and corrective action plans
• Collaborates with internal departments including, but not limited to, SIU, Pharmacy, Medical Management, Provider Relations, Claims, Internal Audit, Regulatory, and Legal
• Develops and maintains contacts/liaison with business partners, law enforcement, regulatory agencies, state, other company staff and external contacts involved in fraud investigation, detection and prevention
• Proactively uses analytical skills to identify all potential areas of member concern including fraud, waste and abuse
• Responsible for assisting department in meeting all state, regulatory and departmental deadlines
• Recommends and participates in development and implementation of internal departmental policies and procedures
• Perform any other job related instructions, as requested

Education and Experience:

• Associate degree in nursing (ADN) or Bachelor of Science/Arts degree in  health or home care,  social work field or equivalent work experience is required
• Minimum of three (3) years of experience in healthcare or homecare is required
• Two to four (2-4) years of investigative experience is preferred

Competencies, Knowledge and Skills:

• Intermediate proficiency level with Microsoft Outlook, Word, Excel, Power Point, and Access is required
• Effective oral and written communication skills
• Ability to perform thorough investigations, develop care plans and see case through resolution and closure; ability to maintain confidentiality
• Ability to organize and prioritize daily workload & meet required deadlines
• Ability to work independently and as a member of a team to deliver high quality work
• Presentation skills necessary
• Knowledge of Medicaid and Medicare, preferred
• Knowledge of medical terminology, medical diagnostic, procedural terms, and instances of FWA
• Critical listening and thinking skills

Licensure and Certification:

• Current, unrestricted license as a Registered Nurse (RN), Licensed Social Worker (LSW) or Licensed Independent Social Worker (LISW) in state of practice is required
• Employment in this position is conditional pending successful clearance of a driver’s license record check.  If the driver’s license record results are unacceptable, the offer will be withdrawn or, if employee has started employment in this position, employment in this position will be terminated

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• May be required to travel up to 25% to meet the needs of the business

Compensation Range:

$61,500.00 - $98,400.00

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

• 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.