Healthcare Investigator

The Affordable Care Act (ACA) requires every state to establish a health insurance exchange (also called Health Insurance MarketplaceSM) to facilitate the purchase of health insurance for individuals and small businesses. Through the Center of Program Integrity (CPI), CMS has strong oversight and internal controls to protect consumers enrolled in the Marketplaces and safeguard taxpayer dollars. CMS develops and enforces rules for insurance agents, and brokers and others who assist with FFM enrollments.  The Marketplace Program Integrity Contractor (MPIC) is designed to support this oversight. Through research, investigation and data analysis, the desired outcomes of the MPIC efforts are to prevent, detect, and resolve noncompliance with Marketplace rules, requirements, and laws; recommend administrative action to CMS; and recommend referral to law enforcement if potential fraud and abuse is identified.

Mid-Level Investigator

Responsibilities

• Work collaboratively within a team of ACA policy expert SMEs and data analysts
• Actively participate in the development of lead and investigation workflows and required data capture within a case management system.
• Strictly follow CMS-approved SOPs as to how to conduct fraud, waste and abuse (FWA) lead reviews and investigations and have input into recommendations for SOP updates as needed.
• Prioritize, evaluate and analyze information in the screening  of claims (leads) of potential fraud, waste and abuse (FWA) within the ACA activity related to enrolling consumers into qualified health plans  and/or agents/brokers non-compliance with regulations.  Make administrative recommendations to CMS, e.g. further investigation, education, site visits
• As needed, develop an Investigative Plan of Action (IPOA) and  with  CMS approval, implement the plan with the support of Junior and Senior Investigators into the potential FWA behavior through such techniques as reactive data analysis, audits, interviews, secret shopping, site visits.
• Within a case management system, comprehensively document in detail all lead and investigation activity and recommendations to CMS.
• As needed with CMS approval correspond with agents/brokers or other government agencies using CMS-approved template
• Actively support preparation of comprehensive reports on the status of leads and investigations required by CMS.
• Asist in  adhoc educational and outreach sessions with partners, e.g. CMS, law enforcement, Agent/brokers, Navigators.
• Safequard PII and PHI
• Infrequent travel may be required

Qualifications

• Bachelor’s degree or equivalency and 2-4 years’ ACA and/or Medicaid-Medicare experience
• Experience with and in-depth understanding of ACA policies and regulations related to consumer enrollments requirements and Agent/Broker and Navigator responsibilities
• Experience conducting investigations within a healthcare environment

Preferred Experience

• Experience with FWA claims and investigations
• Frequently led workgroups to successful completion of goals and milestones
• Highly organized, ability to multi-task and meet deadlines
• Proficient in computer skills, e.g. Microsoft Office-Word, Excel
• Requires only limited oversight to conduct work
• Strong inter-personal and communications skills, both written and oral
• Ability to conceptualize, solve problems and draw conclusions

The likely salary range for this position is $52,000 - $78,000. This is not, however, a guarantee of compensation or salary; rather, salary will be set based on experience, geographic location and possibly contractual requirements and could fall outside of this range.

View information about benefits and our total rewards program.

We are GDIT. The people supporting some of the most complex government, defense, and intelligence projects across the country. We deliver. Bringing the expertise needed to understand and advance critical missions. We transform. Shifting the ways clients invest in, integrate, and innovate technology solutions. We ensure today is safe and tomorrow is smarter. We are there. On the ground, beside our clients, in the lab, and everywhere in between. Offering the technology transformations, strategy, and mission services needed to get the job done.

GDIT is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status, or any other protected class.