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 action to CMS; and recommend referral to law enforcement if potential fraud and abuse is identified .
The Lead Marketplace SME will serve as the expert waste, fraud and abuse (WFA) resource for MPIC team members to include but not limited to Investigators, data analyst, IT specialists, reporting analyst, QA coordinator, and managers. This expert guidance will include the prioritization of the screening of leads, the severity of the WFA, the appropriate type of investigation to conduct, when an investiagtin can be closed and the development of reports provided to the government client.
Specific responsibilities include.
- Actively participate in the refinement/development of Lead Management, Marketplace Investigation, and License Verification SOPs.
- Actively participate in the WFA workflow as activities progress from leads to investigations
- Develop and document a process to be followed by the MPIC team as to how they can effectively receive expert guidance in a timely manner.
- Conduct ongoing evaluation of the guidance process and update as needed . This review will include review of standard status reports and metric. May also include possible report/metric development specific to expert guidance.
- Document all guidance provided to MPIC team.
- Reports to and meet regularly with the Project Director providing weekly status updates on SME activities
- Meet regularly with MPIC Task teams and managers as needed to resolve ongoing questions.
- Bachelors and five or more years of professional and progressive experience with a minimum of three years of experience working on Health Insurance MarketplaceSM issues.
- Individual must demonstrate knowledge and experience in providing expert guidance regarding Marketplace laws, regulations, policies, or operations to individuals performing or managing analysis, education/outreach, and/or investigative activities
- Highly, organized, ability to multi-task and meet deadlines
- Proficient in computer skills, e.g. Microsoft Office-Word, Excel
- Strong inter-personal and communications skills, both written and oral
- Ability to identify needed improvement in processes and make recommendations