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.
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
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
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.
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.