Marketplace Investigator

Type of Requisition:

Regular

Clearance Level Must Currently Possess:

None

Clearance Level Must Be Able to Obtain:

None

Public Trust/Other Required:

None

Job Family:

Intelligence Operations and Analysis

Job Qualifications:

Skills:

Evaluate Information, Microsoft Office 365, Research Analysis

Certifications:

None

Experience:

3 + years of related experience

US Citizenship Required:

No

Job Description:

Marketplace Investigator

The Affordable Care Act (ACA) requires every state to establish a health insurance exchange (also called Health Insurance Marketplace) to facilitate the purchase of health insurance for individuals and small businesses. Through the Center of Program Integrity (CPI), the Centers for Medicare & Medicaid Services (CMS) has strong oversight and internal controls to protect consumers enrolled in the Marketplaces and safeguard taxpayer dollars. CMS develops and enforces rules for insurance agents, brokers, and others who assist with FFM enrollments.  The Marketplace Program Integrity Contract (MPIC) is designed to support this oversight. Through research, investigation, and data analysis, the desired outcomes of the MPIC efforts are to prevent, detect, and resolve noncompliance with Marketplace rules, requirements, and laws; recommend administrative actions to CMS; and recommend referrals to law enforcement if potential fraud and abuse is identified.

HOW YOU WILL MAKE AN IMPACT:

Conducts analysis, research, and outreach in support of an MPIC Team. Research includes review of documents and data; outreach includes interaction with consumers, insurance agents/brokers, and other agencies; analysis includes applying regulations to findings and analysis of data, including enrollment data related to consumer and Agent/Broker activity within the health insurance exchange. Completes and/or supports the preparation of comprehensive reports on the results of analysis and other work completed by team members. Conducts other data analysis and documentation support as needed.

Will focus on reviewing documents provided by agent/brokers in response to Marketplace registration/agreement suspension or termination and preparing recommendation based on review conducted.

• Work collaboratively within a team of ACA policy subject matter experts (SMEs) and data analysts.

• Actively participate in the development of lead and investigation workflows and required data capture within a case management system.

• Strictly follow approved Standard Operating Procedures (SOPs) for conducting investigations and provide input into recommendations for SOP updates as needed.

• Prioritize, evaluate, and analyze information for potential fraud, waste, and abuse (FWA) using data related to consumer enrollments into qualified health plans and/or the associated agents/brokers’ compliance with regulations. 

• Analyze and evaluate enrollment data related to consumer and Agent/Broker activity within the Marketplace.

• As needed, initiate and develop an Investigative Plan of Action (IPOA) and with CMS approval, implement the plan with the support of investigative staff into the potential FWA behavior using various investigative techniques.

• As needed, initiate and develop a Case Summary report, which summarizes investigative findings.

• As needed, make administrative recommendations to CMS based on case summary findings.

• Within a case management and tracking system, comprehensively document in detail all lead and investigative activity.

• As needed, conduct interviews with complainants and/or consumers and with CMS approval correspond with agents/brokers or other government agencies using CMS-approved template

• Actively support preparation of comprehensive reports on the status of leads and investigations as required by CMS.

• As needed, assist in ad-hoc educational and outreach sessions with partners, e.g., CMS, law enforcement, Agent/Brokers, Navigators, etc.

• Safeguard PII and PHI

• Infrequent travel may be required

WHAT YOU'LL NEED TO SUCCEED

• Bachelor’s degree or equivalent experience in healthcare field that includes 2-4 years’ ACA and/or Medicaid-Medicare experience

• 2+ years’ experience with and/or understanding of ACA policies and regulations related to consumer enrollments requirements and Agent/Broker and Navigator responsibilities

• Frequent work with workgroups to s