Team Lead, Program Integrity (Triage)

Job Summary:

The Team Lead, Program Integrity drives and encourages innovative investigative processes and workflows to reduce turnaround time and produce positive investigative outcomes.

Essential Functions:

• Direct the day-to-day activities and leadership of investigative staff to ensure goals of the department are met
• Serve as investigative planning consultant to investigative teams
• Assign cases to investigative staff
• Monitor and prioritize investigation allocation to maximize output and effectiveness of staff to ensure requirements and standards are achieved
• Identify knowledge gaps and provide training opportunities to direct reports
• Lead, arrange and conduct SIU staff meetings
• Coordinate the training of new and existing investigative staff to increase recognition of fraud and abuse indicators and properly direct workflows
• Mentor direct reports including, coaching, development, performance feedback, disciplinary issues, and annual performance evaluations
• Identify workflow and process inefficiencies
• Identify, recommend, develop, and implement internal departmental standard operating procedures
• Collaborate cross functionally between investigative teams and other matrix partners
• Proactively use analytic skills to identify potential areas of FWA and recommend future investigations
• Assist department leadership in identifying, planning, and implementing program integrity metrics and performance indicators
• Assist department leadership in identifying, planning, and implementing Artificial Intelligence (AI) agents and AI-enabled workflows
• Maintain knowledge and stay current on Health Care Fraud trends and schemes
• Recommend process or procedure changes and work with cross departmental teams on identified internal system gaps to mitigate FWA or financial risk
• Assist in response to state and federal regulatory audits
• Identify, assess and control risk to achieve compliance with state and federal integrity rules
• Perform investigative case work and contribute to case creation and lead generation
• Perform any other job related duties as requested.

Education and Experience:

• Bachelor's degree in Health-Related Field, Law Enforcement, or Insurance required
• Master's degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing) preferred
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics or related field required
• Supervisory or leadership experience preferred

Competencies, Knowledge and Skills:

• Intermediate proficiency in Microsoft Outlook, Word, Excel, Access, and Power Point
• Ability to formally present to a wide audience
• Ability to work independently and in a team environment with a high level of confidence
• Highest levels of ethics, integrity, ethics and professionalism in performance of all duties
• Excellent problem solving and decision-making skills with attention to details
• Demonstrated ability in research and drawing conclusions
• Ability to perform intermediate data analysis and to articulate understanding of findings
• Ability to work under limited supervision with moderate latitude for initiative and independent judgment
• Demonstrated leadership skills
• Self-motivated and self-directed
• Knowledge of government program compliance requirements – Medicare, Medicaid, Affordable Care Act (ACA), etc.
• Medical terminology, CPT, HCPCS, ICD codes or medical billing knowledge preferred
• Knowledge of medical insurance and/or state regulatory requirements

Licensure and Certification:

• One of the following certifications is required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) required
• Certified Professional Coder (CPC) preferred
• NHCAA or other fraud and abuse investigation training preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Flexible hours, including possible evenings and/or weekends as needed to serve the needs of our members and may refer members to other CareSource resources.
• Travel is not typically required

Compensation Range:

$72,200.00 - $115,500.00

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

• Fostering a Collaborative Workplace Culture

• 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 environment of belonging that welcomes and supports individuals of all backgrounds.

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