Position Overview
Join the Serco Advisory Services team as a Compliance and Fraud Review Specialist! In this key role, you will support federal programs designed to help millions of individuals seeking government health insurance coverage. Your primary focus will be working on the CMS Eligibility Support (ES) Contract, contributing to external audits, performing essential compliance reviews, and crafting strategies to rectify errors.
About the Role
As a Compliance and Fraud Review Specialist, you will play a vital role in maintaining program integrity, ensuring compliance monitoring, and managing fraud risk activities associated with the Eligibility Support (ES) program. Your responsibilities will include conducting in-depth compliance and fraud reviews, spotting risks and trends, and collaborating with Quality Assurance (QA), Operations, and Program leadership. You will define review criteria, analyze consumer records, evaluate adherence to policies, Standard Operating Procedures (SOPs), and CMS requirements while addressing compliance or fraud risks as required.
Key Responsibilities
- Conduct thorough compliance, fraud, and program integrity reviews aligning with internal processes, SOPs, Document Verification Guides, and CMS regulations.
- Establish review criteria and methodologies for assessments focused on compliance and program integrity.
- Extract, analyze, and review records, applications, and supporting documentation to ensure alignment with eligibility verification and program requirements.
- Detect trends, patterns, anomalies, and potential compliance or fraud-related risk factors.
- Document findings meticulously, including root causes and risk implications.
- Support program integrity and fraud risk management by identifying high-risk submissions or unusual activities.
- Engage in risk-based monitoring activities, enhancing document integrity checks and recognizing patterns.
- Assist in escalating potential compliance, integrity, or fraud issues through established channels.
- Propose improvements to processes, controls, or tools to mitigate identified risks.
- Maintain accurate documentation to support reporting and follow-up actions.
- Facilitate internal compliance reviews and external audits by compiling relevant information and documentation.
- Respond to external audit findings promptly and within set deadlines.
- Work collaboratively with QA, operations, and leadership teams to align compliance initiatives with program objectives.
- Contribute insights and recommendations for enhancing eligibility verification and compliance processes.
Qualifications
- Must be a U.S. Citizen.
- Bachelor's degree in business, Healthcare Administration, Public Administration, Criminal Justice, Information Systems, or a related field (relevant experience may substitute for degree).
- Three years of experience in compliance, quality assurance, program integrity, fraud detection, or eligibility support.
- Familiarity with ACA Marketplace and/or Eligibility Support programs.
- Experience in reviewing records and applications against established criteria, including Document Verification Guides and SOPs.
- Strong analytical abilities to identify patterns, trends, and risks.
- Excellent attention to detail and documentation capabilities.
- Ability to understand and consistently apply policies and procedures.
- Strong written and verbal communication skills.
- Willingness to travel up to 10% as required.
Preferred Qualifications
- Experience in Quality Assurance within ACA Marketplace or ES programs.
- Participation in audits or compliance reviews is a plus.
- Familiarity with fraud risk indicators or program integrity monitoring practices.
- Experience with CMS-directed initiatives or government program oversight.
- Ability to work independently and prioritize multiple reviews effectively.
Be part of a dedicated team at Serco, helping to improve access to healthcare for millions. Submit your application now and take the next step in your career!
Company Overview
Serco Inc. is committed to delivering exceptional services across various sectors, including Defense, Citizen Services, and Transportation. Our workforce of over 9,000 employees strives to make a meaningful impact daily. By joining us, you will have the opportunity to contribute to vital services while promoting customer satisfaction. Discover your potential with Serco!