FRAUD INVESTIGATOR MANAGER - 75724

Executive Service

Background Check:

This position requires a criminal background check. Therefore, you may be required to provide information about your criminal history in order to be considered for this position

Who we are and what we do:

TennCare is Tennessee's managed care Medicaid program that provides health insurance coverage to certain groups of low-income individuals such as pregnant women, children, caretaker relatives of young children, older adults, and adults with physical disabilities. TennCare provides coverage for approximately 1.7 million Tennesseans and operates with an annual budget of approximately $14 billion. It is run by the Division of TennCare with oversight and some funding from the Centers for Medicare and Medicaid Services (CMS).

TennCare's mission is to improve the lives of Tennesseans by providing high-quality cost-effective care. To fulfill that purpose, we equip each employee for active participation and empower teams to communicate and worked collaboratively to improve organizational processes in order to make a difference in the lives our members. Because of the positive impact TennCare has on the lives of the most vulnerable Tennesseans, TennCare employees report that their work provides them with a sense of meaning, purpose, and accomplishment. TennCare leadership understands that employees are our most valuable resource and ensures professional and leadership development are a priority for the agency.

Why Work at TennCare:

TennCare's mission is to improve the lives of Tennesseans by providing high-quality cost-effective care. To fulfill that purpose, we equip each employee for active participation and empower teams to communicate and work collaboratively to improve organizational processes in order to make a difference in the lives of our members. Because of the positive impact TennCare has on the lives of the most vulnerable Tennesseans, TennCare employees report that their work provides them with a sense of meaning, purpose, and accomplishment. TennCare leadership understands that employees are our most valuable resource and ensures professional and leadership development are a priority for the agency.

JOB OVERVIEW:

The office of Program Integrity (OPI) is responsible for the prevention, detection and investigation of alleged provider fraud, waste and/or abuse. OPI collaborates with the Managed Care Contractors (MCCs), law enforcement, and various state and federal agencies to ensure compliance and accountability and protects the financial and health care service integrity of the TennCare program.

The TennCare Fraud Investigations Manager classification is responsible for the prevention, detection, and investigation of alleged provider fraud, waste, and/or abuse (FWA). Typically, this classification supervises and leads a team of Fraud Investigators to carry out such duties and/or has significant oversight duties covering a major area (e.g., Compliance, Project Management, etc.) of TennCare's FWA activities. An incumbent in this classification assumes higher leadership responsibilities and collaborates with TennCare's Managed Care Contractors (MCCs), law enforcement, and various state and federal agencies to investigate FWA activities, ensures compliance and accountability, and protects the financial and healthcare service integrity of the TennCare program.

Key Responsibilities:

• Maintain oversight and supervision of investigation staff who investigate referrals and oversee deliverables submitted by MCCs and other sources.
• Conducts and leads referral meetings with law enforcement and other appropriate internal and external partners.
• Maintain oversight of the Provider Alert List which is distributed to the MCCs and other internal and external partners -Perform auditing functions related to program integrity.
• Provide well written reports including pertinent case information and resources to support findings.

Minimum Qualifications:

• Bachelor's Degree or higher in healthcare, public administration, business administration, criminal justice preferred, or equivalent combination of education and 3 years related experience; Certification or Licensure: AHFI, CFE, CPC, CCS, AHFI, PMP, or RN; Experience in fraud investigations and case management; working knowledge of Medicaid and preferably TennCare's Medicaid program; 3-5 years of project management experience and/or experience with audits and reviews.

OR

• an equivalent combination of education and work experience may be considered.

Desirable Qualifications

• Have working knowledge of TennCare's Medicaid program, medical terminology, medical records to support claims, as well as the claims processing systems of TennCare's contractors.
• Proficient in Microsoft applications including Outlook, Word, Excel and Power Point.
• Ability to analyze claims data through use of software applications (Excel, Power Pivot, Pivot tables, Access, Tableau).
• Ability to work independently and use critical thinking.
• Knowledgeable of TennCare/Medicaid (CMS) and provider guidelines to correctly review payment coverage. -Knowledgeable of Medical terminology, Procedure Codes (ICD-9, ICD-10, HCPCS, CPT, DRGs, etc.) and Medicaid processes.
• Bachelor's Degree or higher in healthcare, public administration, business administration, criminal justice, or equivalent combination of education.
• Certification or Licensure: Accredited Health Care Fraud Investigator, Certified Fraud Examiner, Certified Professional Coder, Certified Coding Specialist, Registered Nurse.
• Experience in fraud investigations and case management.
• Working knowledge of Medicaid and preferably TennCare's Medicaid program -3-5 years of medical records reviews/audits, fraud detection/investigations, and presenting cases.
• Project management experience OR an equivalent combination of education and work experience may be considered.
• Experience auditing various specialties (including, but not limited to Internal Medicine, Pain Management, OB-Gyn, Pharmacy, Dental, Behavioral Health, Long-Term Care, etc.).
• Data Analyst experience with an emphasis on data mining and analyzing claims data for trends and anomalies.
• Familiar with analytical and statistical software RAT-STATS, SAS, Tableau, etc.
• Preferred Certifications/Education -Accredited Health Care Fraud Investigator, Certified Fraud Examiner, Certified Professional Coder, Certified Coding Specialist, Registered Nurse.
• Bachelor's Degree or higher in Healthcare or Criminal Justice preferred or equivalent combination of education and experience.

Pursuant to the State of Tennessee's Workplace Discrimination and Harassment policy, the State is firmly committed to the principle of fair and equal employment opportunities for its citizens and strives to protect the rights and opportunities of all people to seek, obtain, and hold employment without being subjected to illegal discrimination and harassment in the workplace. It is the State's policy to provide an environment free of discrimination and harassment of an individual because of that person's race, color, national origin, age (40 and over), sex, pregnancy, religion, creed, disability, veteran's status or any other category protected by state and/or federal civil rights laws.