Marketplace Investigator

About the Role

Marketplace Investigator supporting the Marketplace Program Integrity Contract (MPIC) for the Centers for Medicare & Medicaid Services (CMS). This role focuses on preventing, detecting, and resolving noncompliance with Affordable Care Act (ACA) Marketplace rules through research, investigation, and data analysis.

How You Will Make An Impact

• Conducts analysis, research, and outreach in support of an MPIC Team, including review of documents and data, interaction with consumers, insurance agents/brokers, and other agencies, and applying regulations to findings and analysis of data, including enrollment data related to consumer and Agent/Broker activity within the health insurance exchange.
• 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.
• Focuses on reviewing documents provided by agent/brokers in response to Marketplace registration/agreement suspension or termination and preparing recommendation based on review conducted.
• Works collaboratively within a team of ACA policy subject matter experts (SMEs) and data analysts.
• Actively participates in the development of lead and investigation workflows and required data capture within a case management system.
• Strictly follows approved Standard Operating Procedures (SOPs) for conducting investigations and provides input into recommendations for SOP updates as needed.
• Prioritizes, evaluates, and analyzes 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.
• Analyzes and evaluates enrollment data related to consumer and Agent/Broker activity within the Marketplace.
• As needed, initiates and develops an Investigative Plan of Action (IPOA) and with CMS approval, implements the plan with the support of investigative staff into the potential FWA behavior using various investigative techniques.
• As needed, initiates and develops a Case Summary report, which summarizes investigative findings.
• As needed, makes administrative recommendations to CMS based on case summary findings.
• Within a case management and tracking system, comprehensively documents in detail all lead and investigative activity.
• As needed, conducts interviews with complainants and/or consumers and with CMS approval corresponds with agents/brokers or other government agencies using CMS-approved template.
• Actively supports preparation of comprehensive reports on the status of leads and investigations as required by CMS.
• As needed, assists in ad-hoc educational and outreach sessions with partners, e.g., CMS, law enforcement, Agent/Brokers, Navigators, etc.
• Safeguards PII and PHI.
• Infrequent travel may be required.

What You'll Need To Succeed

• Bachelor's degree or equivalent experience in healthcare field that includes 2-4 years' ACA and/or Medicaid-Medicare experience.
• 2+ years' 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.

Preferred Skills

• Experience with FWA claims and investigations.

Additional Requirements

• Must be able to pass a CMS background check, which requires residency in the U.S. for 3 of the last 5 years.

Benefits

• 401K with company match.
• Comprehensive health and wellness packages.
• Internal mobility team dedicated to helping you own your career.
• Professional growth opportunities including paid education and certifications.
• Cutting-edge technology you can learn from.
• Rest and recharge with paid vacation and holidays.

Pay & Schedule

• Likely salary range: $69,700 - $94,300 (set based on experience, geographic location and possibly contractual requirements).
• Scheduled Weekly Hours: 40.
• Travel Required: Less than 10%.
• Telecommuting Options: Remote.