Investigator

JOB SUMMARY

This job is responsible for developing and maintaining an anti-fraud program which includes development and delivery of training and filing of Fraud Plans and Reports. The incumbent is responsible for conducting investigations of organizational or functional activities related to alleged fraud, waste and abuse perpetrated by providers, members, facilities, pharmacies, groups and/or employees of the organizations and Subsidiaries. The incumbent is responsible for interviews which might include providers and members and may be conducted onsite or offsite. The incumbent is also responsible for the field investigative work necessary to complete a review of a special project, potential fraud, waste and abuse case, conducting the initial investigations and coordinating the recovery/savings of money related to fraud, waste and abuse. The incumbent must be able to testify in a court of law, prepare cases for referral to various federal, state and local law enforcement entities and work with those agencies through closure of the case. Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements.

Responsibilities

Performs investigations into potential and existing provider and member fraud, waste and abuse activities; Conducts interviews with providers, members or any other individual(s) necessary to complete an assigned investigation or special project; Develops and maintains annual anti-fraud program including facilitating fraud training and fraud awareness day, as well as filing annual fraud plans and reports according to state regulations; Coordinates data extracts by assessing multiple databases both internally and externally; Completes all necessary field investigative work for resolution of alleged fraud/waste and abuse cases or special projects; Provides advisory support to internal and external law enforcement and regulatory agencies; Engages in delivery of audit results and overpayment negotiations; Conducts audits for proactive and investigative purposes to comply with internal audit and regulatory requirements; Prepares cases for referral to federal, state and local law enforcement entities and works with those agencies through closure of the case

Requirements

Bachelor's Degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field; 6 years of related and progressive experience in lieu of Bachelor's degree; 3 years of relevant, progressive experience in the health insurance industry and/or healthcare fraud investigations; Must have knowledge of provider facility payment methodology, claims processing systems and coding and billing proficiency; Must have understanding of technical and financial aspects of the health insurance industry; Strong personal computer skills, along with the ability to use fraud/abuse data mining tools are required; Must possess excellent communication skills and be detailed oriented; Strong written and oral communication skills; Strong relationship building skills; Client focused with strong business acumen; Self-starter with the ability to work under pressure independently and as part of a team; Ability to think strategically and act proactively to create strong trust and confidence with business units; Strong innovative problem-solving capabilities

Nice to have

Master's Degree in Fraud, Forensics Accounting, Business or related field; 1 year in Financial Analysis in an acute care hospital or health insurance setting; 1 year in professional billing, facility Patient Financial Services, HIM, Internal Audit, Professional/Facility Reimbursement or Provider Contracting; Certified Fraud Examiner (CFE); Certified Professional Coder (CPC); Certified Outpatient Coder (COC); Accredited Healthcare Fraud Investigator (AHFI); CPMA, CCA, or CCS