Program Integrity Specialist - DC Contract

Program Integrity Specialist

This position provides an organized approach to the prevention, detection, and reporting of fraud, waste, and abuse. This position is responsible for auditing a percentage of processed claims to validate payment accuracy and to root out incidences of fraud, waste, and abuse. The Program Integrity Specialist operates as the primary resource for investigations, prevention, and program audit-related activities. The specialist must understand key business objectives and health plan operations while assisting with the follow-up and implementation of process and procedural improvements related to audit findings.

Essential Functions

• Conduct audits and review claims. Documents findings and recommendations.
• Request all information from internal or outside sources to ascertain the completeness and validity of claims.
• Research claims as needed.
• Identifies fraud in any aspect of the organization and services provided. This includes, but is not limited to: Employee fraud, Provider fraud, Member fraud eligibility, geographic access, member and facility signatures, Public Transportation, Mileage Reimbursement, Volunteer Driver and Internal fraud detection.
• Document work performed and audit results based on pre-determined standards and guidelines.
• Compile case file documentation and issue findings in accordance with applicable policies and procedures; develop, maintain, and manage cases in the internal case tracking system.
• Create and analyze trended reports for the purpose of identifying opportunities for improvement, assessing the effectiveness of such improvements, and sharing of best practices. Examples include no-shows, frequent demand responses, trip verification, Public Transit trends, etc.
• Exercise independent judgment and discretion in using available resources to identify relevant evidence supporting investigations.
• Prepare internal reports.
• Coordination with other departments as needed.
• Basic knowledge of all State contracts.
• Other duties as assigned

Qualifications Required

• Strong analytical, qualitative, and problem-solving skills with the ability to perform root cause analysis and implement workable solutions
• Ability to multi-task, establish priorities and work independently to achieve objectives
• Ability to function effectively under pressure
• Adaptable and flexible while possessing the aptitude to grasp new concepts and assignments quickly
• Excellent Customer service skills with the ability to interact professionally and effectively with providers and staff from all departments
• Strong interpersonal skills with the desire and capacity to work in a fast-paced environment whether as a team member or as an independent contributor

Minimum Required Education

• A Bachelor's degree or a minimum of two years of investigative experience preferred
• Basic understanding of the NEMT network
• Proficient in Microsoft Office software (Word, Excel, PowerPoint)
• Strong investigative skills
• Strong communication and organization skills
• Demonstrates a strong ethical and professional manner