Marketplace Investigator
A$ A' A' ?Marketplace InvestigatorThe 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 actions to CMS; and recommend referrals to law enforcement if potential fraud and abuse is identified.
Summary:
Conducts analysis of data, including enrollment data related to consumer and Agent/Broker activity within the health insurance exchange in support of an investigative team.
Completes and/or supports the preparation of comprehensive reports on the results of analysis and other work completed by team members.
Conducts other data analysis and documentation support as needed.
ResponsibilitiesWork collaboratively within a team of ACA policy subject matter experts (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 approved Standard Operating Procedures (SOPs) for conducting investigations and provide input into recommendations for SOP updates as needed.
Prioritize, evaluate, and analyze information for potential fraud, waste, and abuse (FWA) using data related to consumer enrollments into qualified health plans and/or the associated agents/brokers' compliance with regulations.
Analyze and evaluateenrollment data related to consumer and Agent/Broker activity within the Marketplace.
As needed, initiate and develop an Investigative Plan of Action (IPOA) and with CMS approval, implement the plan with the support of investigative staff into the potential FWA behavior using various investigative techniques.
As needed, initiate and develop a Case Summary report, which summarizes investigative findings.
As needed, make administrative recommendations to CMS based on case summary findings.
Within a case management and tracking system, comprehensively document in detail all lead and investigative activity.
As needed, conduct interviews with complainants and/or consumers and with CMS approval correspond with agents/brokers or other government agencies using CMS-approved templateActivelysupport preparation of comprehensive reports on the status of leads and investigations as required by CMS.
As needed, assist in ad-hoc educational and outreach sessions with partners, eg, CMS, law enforcement, Agent/Brokers, Navigators, etc.
Safeguard PII and PHIInfrequent travel may be requiredQualificationsBachelor's degree or equivalency in healthcare field that includes 2-4 years' ACA and/or Medicaid-Medicare experienceExperience with and/or understanding of ACA policies and regulations related to consumer enrollments requirements and Agent/Broker and Navigator responsibilitiesFrequent work with workgroups to successful completion of goals and milestonesExperience reviewing complex data reportsHighly organized, ability to multi-task, and meet deadlinesProficient in computer skills, for example Microsoft Office-Word, ExcelRequires only limited oversight to conduct workStrong inter-personal and communications skills, both written and oralExperience in conducting telephonic and in-person interviewsAbility to conceptualize, solve problems, and draw conclusions Value-Add ExperienceA'.
Experience with FWA claims and investigationsVisual Connections Benefits package including:
Full Medical, Dental, Prescription and Vision health care10 Paid Holidays annuallyPaid time offShort Term, Long Term Disability and Life InsuranceEmployee Assistance Program (EAP)Training and Development opportunities including professional certification and educational reimbursement.
Estimated Salary: $20 to $28 per hour based on qualifications.
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 actions to CMS; and recommend referrals to law enforcement if potential fraud and abuse is identified.
Summary:
Conducts analysis of data, including enrollment data related to consumer and Agent/Broker activity within the health insurance exchange in support of an investigative team.
Completes and/or supports the preparation of comprehensive reports on the results of analysis and other work completed by team members.
Conducts other data analysis and documentation support as needed.
ResponsibilitiesWork collaboratively within a team of ACA policy subject matter experts (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 approved Standard Operating Procedures (SOPs) for conducting investigations and provide input into recommendations for SOP updates as needed.
Prioritize, evaluate, and analyze information for potential fraud, waste, and abuse (FWA) using data related to consumer enrollments into qualified health plans and/or the associated agents/brokers' compliance with regulations.
Analyze and evaluateenrollment data related to consumer and Agent/Broker activity within the Marketplace.
As needed, initiate and develop an Investigative Plan of Action (IPOA) and with CMS approval, implement the plan with the support of investigative staff into the potential FWA behavior using various investigative techniques.
As needed, initiate and develop a Case Summary report, which summarizes investigative findings.
As needed, make administrative recommendations to CMS based on case summary findings.
Within a case management and tracking system, comprehensively document in detail all lead and investigative activity.
As needed, conduct interviews with complainants and/or consumers and with CMS approval correspond with agents/brokers or other government agencies using CMS-approved templateActivelysupport preparation of comprehensive reports on the status of leads and investigations as required by CMS.
As needed, assist in ad-hoc educational and outreach sessions with partners, eg, CMS, law enforcement, Agent/Brokers, Navigators, etc.
Safeguard PII and PHIInfrequent travel may be requiredQualificationsBachelor's degree or equivalency in healthcare field that includes 2-4 years' ACA and/or Medicaid-Medicare experienceExperience with and/or understanding of ACA policies and regulations related to consumer enrollments requirements and Agent/Broker and Navigator responsibilitiesFrequent work with workgroups to successful completion of goals and milestonesExperience reviewing complex data reportsHighly organized, ability to multi-task, and meet deadlinesProficient in computer skills, for example Microsoft Office-Word, ExcelRequires only limited oversight to conduct workStrong inter-personal and communications skills, both written and oralExperience in conducting telephonic and in-person interviewsAbility to conceptualize, solve problems, and draw conclusions Value-Add ExperienceA'.
Experience with FWA claims and investigationsVisual Connections Benefits package including:
Full Medical, Dental, Prescription and Vision health care10 Paid Holidays annuallyPaid time offShort Term, Long Term Disability and Life InsuranceEmployee Assistance Program (EAP)Training and Development opportunities including professional certification and educational reimbursement.
Estimated Salary: $20 to $28 per hour based on qualifications.
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