We’re Hiring

Visual Connections, LLC is seeking Jr Journeyman Investigator.  As a Jr Journeyman Investigator you will conduct analysis of data, including enrollment data related to consumer and Agent/Broker activity within the health insurance exchange in support of an investigative team. Complete and/or support the preparation of comprehensive reports on the results of analysis and other work completed by team members. Conduct other data analysis and documentation support as needed.

The 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.

Duties,

• Work 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 evaluate enrollment 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 template

• Actively support 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, e.g., CMS, law enforcement, Agent/Brokers, Navigators, etc.

• Safeguard PII and PHI

• Infrequent travel may be required

Qualifications

• Bachelor’s degree or equivalency in healthcare field that includes 2-4 years’ ACA and/or Medicaid-Medicare experience

• 2 or more years’ experience with and/or understanding of ACA policies and regulations related to consumer enrollments requirements and Agent/Broker and Navigator responsibilities

• Typically performs all functional duties independently.

• Investigators: Gather, analyze, compile and report information regarding individuals or organizations to clients, or detect occurrences of unlawful acts or infractions of rules.BS/BA or equivalency

• Highly organized, ability to multi-task and meet deadlines

• Proficient in computer skills, e.g. Microsoft Office-Word, Excel

• Requires minimal oversight to conduct work

• Strong inter-personal and communications skills, both written and oral

• Ability to conceptualize, solve problems and draw conclusions

• Ability to identify needed improvement in processes and make recommendations

Specific position qualifications are:

• 3 to 10 years of experience in investigating FWA.

• Take a lead role in working collaboratively with ACA policy expert SME sand data analysts

• Take a lead role in the development of lead and investigation workflows and required data capture within a case management system

• Strictly follow CMS-approved SOPs as to how to conduct fraud, waste and abuse (FWA) reviews and investigations and make recommendations for SOP updates as needed.

• Prioritize, evaluate and analyze information in the screening of claims (leads) of potential fraud, waste and abuse (FWA) within the ACA activity related to enrolling consumers into qualified health plans and/or agents/brokers non-compliance with regulations. Make administrative recommendations to CMS, e.g. further investigation, education, site visits

• As needed develop an Investigative Plan of Action (IPOA) and with CMS approval, implement and lead the plan with the support of junior and mid-level investigators into the most complex, potential FWA behavior through such techniques as reactive data analysis, audits, interviews, secret shopping, site visits

• Comprehensively document in detail all lead and investigation activity and recommendations to CMS within a case management system

• As needed with CMS approval correspond with agents/brokers and/or other government agencies using CMS-approved template

• Ensure the development of comprehensive reports on the status of the leads and investigations required by CMS

• Develop and conduct ad hoc educational and outreach sessions with partners, e.g. CMS, law enforcement, Agent/brokers, Navigators

• Safeguard PII and PHI