Clinical Investigator (Remote, North Carolina Based)

The Clinical Investigator monitors service delivery for program integrity through fraud and abuse investigations and audits, including review of claims data, clinical records and reference materials, investigative interviewing, provider education and technical assistance, and monitoring implementation of provider corrective actions. The Investigator reports overpayments and other irregularities and confers with Special Investigations Unit, Senior Management, Chief Compliance Officer and General Counsel as needed. 

This position will allow the successful candidate to work primarily remote and be a resident of North Carolina or reside within forty (40) miles of the North Carolina border.  There is no expectation of being in the office routinely, but the hire will travel to provider sites to conduct audits/investigations in the vicinity of their designated office location.

Responsibilities & Duties

Conduct Audit/Investigations and prepare reports

• Review allegation(s), conduct preliminary investigation and make disposition recommendations using independent judgment
• Develop audit/investigation plans and tools based upon alleged non-compliance and data analytics
• Request and/or collect medical records, personnel records, policies/procedures, compliance plans, and other documents from providers based on audit/investigation plans
• Systematically and accurately collect, document, and store evidence
• Conduct post-payment audits of Medicaid and State funded providers to ensure that services are rendered in accordance with established state and federal rules, regulations, policies, and terms of provider contractual agreements with the state
• Identify inappropriate billing and overpayments
• Utilize clinical knowledge and experience to determine if documented services were clinically appropriate and/or medically necessary
• Conduct interviews with provider employees, former employees, recipients of services, and other witnesses
• Document allegations, investigative activities, and findings in a detailed audit/investigation report
• Work with the Special Investigations Supervisor and Investigative Team to support investigative activities
• Assure that individuals served do not pay for health services inappropriately
• Track allegations of fraud, waste, and abuse in a case management system from referral to final disposition
• Consult with the Corporate Compliance Unit when potential internal compliance issues are identified

Consult on cases

• Provide clinical guidance to non-clinical staff on documentation obtained from providers
• Provide guidance to non-clinical staff on Medicaid Clinical Coverage Policies and State Service Definitions and by participating in ad hoc meetings related to clinical regulatory matters
• Participate iin ad hoc meetings related to clinical matters

Conduct Regulatory Review/ Research

• Diligently research clinical policies, administrative code, federal/state laws in order to assess for non-compliance

Analyze data

• Analyze data from a variety of sources, including but not limited to claims, authorizations, credentialing/enrollment, grievances, prior audits/investigations, incarceration records, incident reports, policies/procedures, to inform decision making
• Utilize various MicroStrategy reports data during the investigation process
• Analyze claims data to determine if an allegation is supported
• Analyze claims data during investigations to determine if there are indicators of fraud/abuse other than the allegation received
• Identify other data sources to review during investigations based on the allegation(s)

Provide Case reports/presentations to internal and external stakeholders

• Present audit/investigation findings and make disposition recommendations using independent judgment to the Chief Compliance and Risk Officer, Senior Director of Program Integrity, Special Investigations Supervisor, and Alliance Compliance Committee
• Present case status updates in individual supervision sessions, unit team meetings, Division meetings (as designated by supervisor), and to NC Department of Justice (as requested)
• Conduct and participate in Investigation Planning meetings with the Investigation Team
• Interpret and convey highly technical information to others

Provide Technical Assistance/Education

• Educate providers on the errors identified in the audit and investigation process
• Recognize when providers can improve through technical assistance (TA) rather than full investigation when FWA is not evident and/or pervasive;
• Recognize quality of care issues in order to make recommendations to appropriate entities/authorities

Monitor Provider Action and Follow-Up

• Document Improper Payment Charts, Statements of Deficiency, provides feedback and technical assistance to providers as needed/requested, and follows up on provider corrective action through the probation process, as applicable
• Prepare for and participate in provider appeal process and/or court hearings to explain and defend audit/investigation findings

Recommend policy, procedure, or process changes

• Recommends revisions to Alliance Health procedures and policies

Minimum Requirements

Education & Experience

Graduation from an accredited school of Nursing with a Registered Nurse (RN) license and five (5) years relevant post-graduate experience. OR Master’s degree in human services/social sciences, health care compliance, analytics, government/public administration, auditing, security management, criminal justice, or pre-law and Five (5) years relevant post-graduate experience. Special Requirement- Current, unencumbered clinical license as an LCSW, LCMHC, LMFT, LCAS, LPA or RN

Preferred

• Health care industry and/or Medicare/Medicaid/Behavioral Health experience and knowledge
• SIU and/or regulatory compliance work experience
• National Certified Investigator and Inspector Training (NCIT) Basic and Specialized

Knowledge, Skills, & Abilities

• Knowledge of Health care industry and/or Medicare/Medicaid/Behavioral Health
• Knowledge of the state and federal Medicaid laws, state and federal criminal and civil fraud laws, regulations, policies, rules, guidelines, service limitations, and various Medicaid programs
• Knowledge and proficiency in claims adjudication standards & procedures
• Knowledge of investigative methods and procedures 
• High degree of integrity and confidentiality required handling information that is considered personal and confidential
• Skill in using Microsoft Office products (such as Word, Excel, Outlook, etc.)
• Analytical skills and ability to make deductions; logical and sequential thinker
• Strong verbal and written communication skills. Ability to write clear, accurate and concise rationale in support of findings
• Ability to manage time, prioritize work, and use problem-solving approaches
• Ability to interpret contractual agreements, business-oriented statistics medical/administrative services and records
• Ability to identify resources, gather evidence, analyze raw data and generate reports
• A general understanding of all major managed care functions in particular as it relates to prior authorization, utilization reviews, grievance management, provider credentialing and monitoring
• Knowledge of the Alliance Health service benefit plans and network providers

Salary Range