Investigations Specialist

Responsibilities:

The Investigations Specialist reports to the Director of Medicare Advantage Appeals and Grievances and conducts, resolves and documents various investigations, including but not limited to member, sales and marketing, compliance hotline, fraud waste and abuse investigations that may originate as grievances, CTM, Department of Insurance or internal health plan and other government entity complaint.  In addition, the specialist (1) interacts with health plan members and providers via the telephone and in writing to explain the complaint process, (2) corresponds in writing with members, providers, regulatory agencies and third parties regarding the complaint process and resolution, (3) will have the capacity to learn and utilize various databases and other sources of information whether maintained by the health plan, regulatory agencies or third parties, (4) tracks and trends complaints for reporting to compliance committees, the Board of Directors and CMS, (5) recommends and monitors improvements in training, policies or documentation to minimize complaints, (6) develops and manages complaint database, including periodic evaluation and upgrades, (7) assists the Director of Medicare Appeals and Grievances in the development and implementation of complaint investigation  policies and procedures; and root cause analyses/remediation actions related to complaints and other investigations; (8) develops and designs reports related to investigations;  and (9) performs other tasks as assigned.  The Investigations Specialist must have a strong work ethic with flexibility to work after-hours with little notice when required.

Education & Experience:

• 1 to 3 year’s experience resolving and documenting various investigations.
• Working knowledge of Medicare Advantage, Original Medicare and Medicare grievance and complaint regulations.
• Medicare Managed Care and Prescription Drug Manuals, Complaints Tracking Module Standard Operating Procedures.
• High School/GED required
• Bachelor’s Degree or related experience.
• Skilled at use of Excel, PowerPoint presentations.
• Superior writing and presentation skills.
• Ability to learn new processes and responsibilities as assigned.
• Willing to work in fast-paced, changing environment.
• Thrives on change and is readily accepts new assignments and challenges.
• Report design, management and oversight.
• Self-development/self-starter.
• Time management and well-organized.
• Capable of presenting complex topics in a focused, business-oriented manner.
• Capable of leading peers to resolve issues and motivates others.