We’re Hiring

Marketplace Investigator

Visual Connections, LLC is seeking a Marketplace Investigator. The Affordable Care Act (ACA) requires every state to establish a health insurance exchange (also called Health Insurance Marketplace(SM) 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. to support the VPM project with our General Dynamics client. In this role you will provide project management support, QA management as well as process improvement requests. 

Job 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.

Primary Roles & Responsibilities:

  • 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

General Qualifications:

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

  • Experience with and/or understanding of ACA policies and regulations related to consumer enrollments requirements and Agent/Broker and Navigator responsibilities

  • Frequent work with workgroups to successful completion of goals and milestones

  • Experience reviewing complex data reports

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

  • Proficient in computer skills, for example Microsoft Office-Word, Excel

  • Requires only limited oversight to conduct work

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

  • Experience in conducting telephonic and in-person interviews

  • Ability to conceptualize, solve problems, and draw conclusions

Value-Add Experience:

  • Experience with FWA claims and investigations

Fulltime remote position; No travel

Visual Connections, LLC offers a full benefits package including:

  • Full Medical, Dental, Prescription and Vision health care

  • 10 Paid Holidays annually

  • Paid time off

  • Short Term, Long Term Disability and Life Insurance

  • Employee Assistance Program (EAP)

Training and Development opportunities including professional certification and educational reimbursement

Visual Connections, LLC provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws. Visual Connections, LLC complies with applicable state and local laws governing non-discrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

We are a Service-Disabled, Veteran-Owned Small Business; a Minority-owned business; a Small Disadvantaged Business and a Certified Maryland Minority and Disadvantage Business Enterprise. We were established in 2007 to provide public and private sector clients with robust web-based applications, Health IT and Portfolio and Program Management services. We have proven ourselves to be valuable partners who can deliver both qualitative and quantitative results to our clients. Our versatile, efficient and experienced team has a stellar record of past performance, working with the Department of Defense (DoD), Department of Health and Human Services (DHHS), Veterans Health Administration (VHA), Blue Cross Blue Shield (BCBS), Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC). With an employee base well versed in different disciplines, we are able to deliver the highest quality customized solutions.