Healthcare Marketplace Investigator II (Full-time, Remote)

About Us

Integrity Management Services, Inc. (IntegrityM) is an award-winning, women-owned small business specializing in assisting government and commercial clients in compliance and program integrity efforts, including the prevention and detection of fraud, waste and abuse in government programs. Results are achieved through data analytics, technology solutions, audit, investigation, and medical review.

At IntegrityM, we offer a culture of opportunity, recognition, collaboration, compassion and supporting our community. We thrive off of these fundamental elements that make IntegrityM a great place to work. Our small, flexible workplace offers an exceptional quality of life and promotes corporate-driven sustainability. We deliver creative solutions that exceed goals and foster a dynamic, idea-driven environment that nurtures our employees’ professional development. Large company perks…Small company feel!

We are now seeking a Marketplace Senior Investigator to join our team.

Responsibilities:

• Typically performs all functional duties independently.

• Gather, analyze, compile and report information regarding individuals or organizations to clients, or detect occurrences of unlawful acts or infractions of rules.

• Take a lead role in working collaboratively with ACA policy expert SME sand data analysts

• Take a lead role the development of lead and investigation workflows and required data capture within a case management system

• Strictly follow CMS-approved SOPs as to how to conduct fraud, waste and abuse (FWA) reviews and investigations and make recommendations for SOP updates as needed.

• Prioritize, evaluate and analyze information in the screening of claims (leads) of potential fraud, waste and abuse (FWA) within the ACA activity related to enrolling consumers into qualified health plans and/or agents/brokers non-compliance with regulations. Make administrative recommendations to CMS, e.g. further investigation, education, site visits

• As needed develop an Investigative Plan of Action (IPOA) and with CMS approval, implement and lead the plan with the support of junior and mid-level investigators into the most complex, potential FWA behavior through such techniques as reactive data analysis, audits, interviews, secret shopping, site visits

• Comprehensively document in detail all lead and investigation activity and recommendations to CMS within a case management system

• As needed with CMS approval correspond with agents/brokers and/or other government agencies using CMS-approved template

• Ensure the development of comprehensive reports on the status of the leads and investigations required by CMS

• Develop and conduct ad hoc educational and outreach sessions with partners, e.g. CMS, law enforcement, Agent/brokers, Navigators

• Safeguard PII and PHI

Requirements

Specific position qualifications are:

• BA/BS or MA/MS degree (or equivalent experience).

• 3 to 10 years of experience in investigating FWA.

• Highly organized, ability to multi-task and meet deadlines

• Proficient in computer skills, e.g. Microsoft Office-Word, Excel

• Requires minimal oversight to conduct work

• Strong inter-personal and communications skills, both written and oral

• Ability to conceptualize, solve problems and draw conclusions

• Ability to identify needed improvement in processes and make recommendations

Must be able to pass a background screening process which consists of education, employment, credit, criminal, and drug test.