TBI MEDICAID FRAUD AUDITOR - 08122026-79993

Job Information

State of Tennessee Job Information

LOCATION OF (1) POSITION(S) TO BE FILLED: TENNESSEE BUREAU OF INVESTIGATION (T.B.I), DAVIDSON COUNTY

Medicaid Fraud Control Division - TBI Headquarters, Nashville, TN

For more information, visit the link below:

https://www.tbijobs.com

Qualifications

Education and Experience: A Bachelor's degree and 4 years of experience with a healthcare insurance provider (MCO), TennCare, Center for Medicare and Medicaid Services (CMS), Unified Program Integrity Contractors (UPIC), a Medicaid Fraud Control department, or related field.

OR

An associate's degree and 6 years of experience with a healthcare insurance provider (MCO), TennCare, Center for Medicare and Medicaid Services (CMS), Unified Program Integrity Contractors (UPIC), a Medicaid Fraud Control department, or related field; and a nationally recognized certification as an Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or other relevant certification.

OR

A high School diploma or equivalent and 8 years of experience with a healthcare insurance provider (MCO), TennCare, Center for Medicare and Medicaid Services (CMS), Unified Program Integrity Contractors (UPIC), a Medicaid Fraud Control department, or related field; and a nationally recognized certification as an Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or other relevant certification.

Overview

Responsible for supporting TBI Medicaid Fraud Division's (MFCD) investigative efforts to pursue provider driven healthcare fraud and patient abuse allegations. The employee in this class is responsible for auditing records, reviewing, analyzing, interpreting and explaining data in support of TBI Medicaid fraud civil and criminal investigations. Under general supervision, is responsible for Medicaid fraud audit work of considerable difficulty; and performs related work as required.

Responsibilities

• Reviews and screens potential fraud leads generated through data mining tools to determine credibility and prepare formal fraud referrals.
• Evaluates tips and referrals from internal and external sources [e.g.,TennCare Office of Program Integrity (OPI), Adult Protective Services (APS), the TBI-MFCD Hotline, Managed Care Organizations (MCOs), the National Association of Medicaid Fraud Control Unit work groups (NAMFCU)] to determine whether investigative action is warranted.
• Audits financial records, including bank and tax documents, to support civil and criminal Medicaid fraud investigations.
• Analyzes claims data and prepares summary reports using Controlled Substance Monitoring Database (CSMD), Tenn Care billing, Dental and Pharmacy Benefits Managers (PBMs) data, etc., to support investigations.
• Reviews and audits Electronic Health Records (EHR)/ Electronic Medical Records (EMR) and patient abuse referral reports for evidence relevant to Medicaid fraud cases.
• Identifies anomalies, outliers, and trends in medical, financial, and claims data to detect potential fraudulent activity.
• Analyzes personally identifiable information (PII) to identify subjects, victims, and potential witnesses in investigations.
• Exchanges investigative information with state and federal partner agencies to support coordinated Medicaid fraud enforcement efforts.

Competencies (KSA's)

Competencies:
1. Decision Quality
2. Manages Complexity
3. Resourcefulness
4. Instills Trust
5. Communicates Effectively

Knowledges:
1. Law and Government
2. Medicine and Dentistry

Skills:
1. Writing
2. Reading Comprehension
3. Monitoring

Abilities:
1. Written Comprehension
2. Deductive Reasoning
3. Information Ordering

Tools & Equipment

1. Computer
2. Telephone
3. Copy/Fax/Scanner

TN Driver Standards

State of Tennessee positions that may involve driving responsibilities require candidates to meet the following minimum driver qualifications:

• A valid driver's license
• For the past five years, the candidate's driver record must not have record of the following violations: driving under the influence (DUI), reckless driving, license suspension for moving violations, more than 4 moving violations.

Please include your Driver's License Information under the Licenses and Certifications section of your application.

**Agencies may allow an exception based on other factors.