TENNCARE FRAUD INVESTIGATOR - 67295

Executive Service

The Division of TennCare is dedicated to providing our employees with a hybrid work environment. All TennCare positions have a combination of work from home and work in the office, which varies by position, department, and business need. You may review the specific expectations with our hiring team.

Background Check:

This position requires a 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.

Job Overview:

Medicaid fraud, waste, and abuse has become a priority for CMS. Over the years, fraud, waste and abuse rules, regulations, and requirements placed on the State Medicaid agencies have increased, thereby OPI has created a Regulatory Unit to meet new and existing CMS requirements.

The responsibilities of the new unit will encompass provider suspensions, terminations, recoupments, settlements, manage deliverables from the MCCs related to CMS Provider Exception List, 42 CFR Part 455 Subpart B Attestations, Conflict of Interest, Prohibition of Illegal Immigrants, and Ownership and Financial Disclosure Report, and the Provider Review committee. The position will report to the Regulatory Manager.

Key Responsibilities:

• Assist Manager with administrative actions and overpayments.
• Assist Manager with surveys/audits, and annual business requirements.
• Coordinate the Unified Program Integrity Contract (UPIC) meetings, and review reports to ensure there are no investigations currently open.
• Review MCC documents submitted to TN Department of Commerce and Insurance for accuracy regarding FWA.
• Reconcile TBI, AG, and Fiscal's settlement spreadsheets.
• Update settlements in Pallium, OPI's case management software.
• Review deliverables from Managed Care Partners.
• Verification of terminated providers for outside entities.
• Assist with special projects as needed.

Minimum Qualifications:

Bachelor's Degree with a major in a health-related field or Criminal Justice, or a minimum of 3 years of related clinical experience; Experience researching medical policy, rules and regulations; General knowledge of medical/dental claims processing; Accredited Health Care Fraud Investigator (AHFI), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Registered Nurse (RN), Certified Fraud Examiner (CFE); Intermediate expertise with analytical and statistical software such as RAT-STATS, SAS etc.; Working knowledge of Medicaid and preferably TennCare's Medicaid program.

OR

An equivalent combination of education and work experience may be considered.

Desirable Qualifications:

Bachelor's Degree or higher in Healthcare or Criminal Justice preferred or equivalent combination of education and experience.

Certified Professional Compliance Officer (CPCO)

• Detail oriented.
• Highly organized.
• Active listening.
• Critical thinking.
• Ability to identify group needs and suggest solutions.
• Ability to adapt to changing priorities and deadlines.
• Ability to foster and maintain cohesive working relationships.
• Excellent writing and communication skills required.
• Have working knowledge of Medicaid and preferably TennCare's Medicaid program.

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.