NCI: As the Sr. Benefit Integrity Analyst (Benefit Integrity Analyst, Sr.) at AdvanceMed, a subsidiary of NCI, you will perform in-depth evaluation of potential fraud cases and develop complex investigations that involve high dollar amounts, sensitive issues, or that otherwise meet criteria for referral to OIG, and prepare those cases for referral to OIG. You will provide peer leadership for BI Analysts through mentoring, on-site audit leadership, and hands-on training of investigative techniques, and will be a critical contributor in meeting AdvanceMed’s mission, “To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste, and abuse."
Highlights of Responsibilities:
- Conducts independent investigations resulting from the discovery of situations that potentially involve fraud or abuse.
- Utilizes data analysis techniques to detect aberrancies in Medicare claims data and proactively seeks out and develops leads received from a variety of sources (e.g., CMS, OIG, fraud alerts).
- Reviews information contained in standard claims processing system files (e.g. claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare policies and initiates appropriate action.
- Makes potential fraud determinations by utilizing a variety of sources such as the ZPIC’s Internal guidelines, Medicare provider manuals, Medicare regulations, and the Social Security Act.
- Reviews, analyzes, develops and prepares potential Fraud Alerts and submits these to CMS for consideration for publication.
- Shares information on current fraud investigations with other Medicare contractors and alerts the CMS COTR to cases being developed in other regions. Reviews requests for data received from the OIG, DOJ, etc.,
- Makes initial determinations regarding the ZPIC’s ability to comply, communicates with the requesting agency and the CMS COTR as necessary, and prepares the material for transmittal.
- Ensures that the ZPIC maintains effective communication and coordination with appropriate law enforcement agencies, (OIG, FBI, etc), as well as other government federal and state agencies and organizations involved in combating fraud and abuse.
- Prepares, develops, and participates in provider, beneficiary, law enforcement, or staff training as related to Medicare Fraud and Abuse issues.
- Provides leadership and participates in onsite audits in conjunction with investigation development.
- Provides support to Fraud Analysts in the preparation and development of tasks related to onsite audits.
- Supports all assigned tasks relating to hearing/appeal and ALJ issues.
- Maintains chain of custody on all documents and follows all confidentiality and security guidelines in accordance with CMS and ZPIC requirements.
- Compiles and maintains various documentation and other reporting requirements as required.
- Performs other duties as assigned by management including special projects that demonstrate team leadership abilities and support the efforts and goals of the ZPIC.
Preferred Education and Experience:
- High school diploma.
- Minimum of three years of fraud investigation experience.
- Must have and maintain a valid driver’s license issued by the state of residence
- Candidates who have successfully completed college or technical degree programs related to the position (e.g. criminal justice, statistics, data analysis, etc.).
- Previous experience investigating healthcare related fraud.
- Experience testifying in state and/or federal court.
- Knowledge of statistics, data analysis techniques, and PSC skills.
At NCI, we’re more than just a paycheck…
We offer significant opportunity for growth at NCI – Adding more and more employees and company locations nationwide, we continue to seek top talent to ensure our path of innovation, growth and unmatched customer experience. We reward our employees with competitive compensation, flexible time off, retirement plan with company match and much more…
MEDICAL/DENTAL/VISION PROGRAMS - NCI offers three medical plan options to meet the personal health needs and budgets of our full-time employees and their families. All plans provide our employees and their eligible dependents with major medical and prescription drug coverage. The dental plan provides coverage options so as to ensure our full-time employees and their eligible dependents are able to follow a regularly scheduled program of dental care with their providers of choice. A vision maintenance plan offers a cost-savings option for our full-time employees and their families in need of comprehensive annual eye exams, prescription glasses, and contact lenses.
STOCK & WEALTH - NCI’s 401(k) Profit Sharing Plan is eligible to all full-time and regular part-time employees. Employees may elect to have contributions invested in any of the 15 different investment funds, five retirement-date-based funds, or three different portfolio options available under the plan. The company matching contribution is equal to 50% of employee elected pre-tax contributions up to 6% of eligible pay, subject to the IRS maximum.
LIFE INSURANCE - NCI provides company paid Basic Life/ AD&D Insurance Coverage. The basic coverage benefit is equal to one times (1X) an employee's annual base salary. Employees may also opt for a generous flat rate insurance coverage. For coverage above the company-provided limits, employees may purchase supplemental insurance coverage for themselves and their family members.
WORK/LIFE BALANCE - All employees are eligible for additional programs including Paid Time Off (PTO).
- Flexible Spending Programs
- Employee Assistance Program (EAP) for employees and their immediate family
- Health Club Reimbursement through NCI’s Wellness Program
It is your turn… Choose your career path and become part of the NCI team where you will be valued for your unique skills and capabilities and where you will be rewarded for key contributions to NCI and our customers.
Make the commitment and take the next step towards joining the NCI Team. Our application process will take approximately 5-10 minutes to complete.
If you do not meet the minimum qualifications for this position, please review our current openings now and in the future. Thank you for your interest in NCI!
It is the policy of NCI to provide equal opportunity in recruiting, hiring, training, and promoting individuals in all job categories without regard to race, color, religion, national origin, gender, age, sexual orientation, disability or veteran status.
The information above has been designed to indicate the general nature and level of work performed by employees within the classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this position.
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