Program Integrity Analyst II

CES is looking for a Program Integrity Analyst II (PIA). The PIA is responsible for evaluation and development of leads, complaints, and/or investigations to verify allegations of potential fraud. Recommends and/or implements appropriate administrative actions.

Duties/Responsibilities:

• Perform evaluation and development of leads, complaints, and/or investigations to determine if further investigation and administrative actions are warranted.
• Conduct independent reviews resulting from the discovery of situations that potentially involve fraud or abuse.
• Utilize basic data analysis techniques to detect aberrancies in Medicare and Medicaid claims data, and proactively seeks out and develops leads/investigations received from a variety of sources (e.g., CMS, OIG, 1-800-MEDICARE, and fraud alerts).
• Review information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare and Medicaid policies and initiate appropriate action.
• Make potential fraud determinations by utilizing a variety of sources such as internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid regulations, and the Social Security Act.
• Compile and maintain documentation and information related to investigations, cases, and/or leads.
• Participate in onsite audits in conjunction with investigation development.
• Develop and prepare potential Fraud Alerts and program vulnerabilities for submission to CMS. Share information on current fraud investigations with other Medicare contractors and state Medicaid agencies, law enforcement, and other applicable stakeholders.
• Prepare and submit external correspondence and reports, including, but not limited to, overpayment letters, fraud case referrals, suspensions, rebuttals, Medicare/Medicaid findings reports, and administrative action recommendations.
• Submit suspension notifications to providers upon suspension approval.
• Prepare and submit ADR letters to providers associated with requests for medical record requests or suspension overpayment determinations.
• Serve as mentor/trainer to new Program Integrity staff.
• Perform other duties as assigned by PI Supervisor or PI Manager that contribute to task order goals and objectives

Preferred qualifications/skills:

• Effective time management and prioritization skills.
• Ability to work independently.
• Ability to plan and manage multiple assignments, projects and adjust to changing priorities.
• Effective communication skills.
• High School Diploma or G.E.D equivalent.
• 1-5 years related experience.

Other:
· Equal Opportunity Employer/Veterans/Disabled. · For more information about CES, please visit www.cesnb.com