Description
We're building a world of health around every individual , shaping a more connected, convenient and compassionate health experience.
As a Senior Investigator, you will conduct high-level, complex investigations of known or suspected acts of healthcare fraud and abuse.
Responsibilities:
- Investigate to prevent payment of fraudulent claims submitted to the Medicaid lines of business
- Research and prepare cases for clinical and legal review
- Document all appropriate case activity in case tracking system
- Facilitate feedback with providers related to clinical findings
- Initiate proactive data mining to identify aberrant billing patterns
- Make referrals, both internal and external, in the required timeframe
- Facilitate the recovery of company and customer money lost as a result of fraud matters
- Provide on-the-job training to new Investigators and guidance for less experienced or skilled Investigators
- Assist Investigators in identifying resources and best course of action on investigations
- Serve as backup to the Team Leader as necessary
- Cooperate with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters
- Demonstrate high level of knowledge and expertise during interactions and act confidently when providing testimony during civil and criminal proceedings
- Give presentations to internal and external customers regarding healthcare fraud matters and approach to fighting fraud
- Provide input regarding controls for monitoring fraud-related issues within business units
Required Qualifications:
- 3+ years investigative experience in healthcare fraud and abuse matters
- Working knowledge of medical coding; CPT, HCPCS, ICD10
- Experience with Microsoft Office, advanced skills in Excel (pivot tables)
- Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)
Preferred Qualifications:
- Previous Medicaid/Medicare investigatory experience
- Credentials such as certification from the Association of Certified Fraud Examiners (CFE), or accreditation from the National Health Care Anti-Fraud Association (AHFI)
- Knowledge of complex clinical issues
- Strong communication and customer service skills
- Strong analytical and research skills
- Proficient in researching information and identifying information resources
- Strong verbal and written communication skills
Education:
- Bachelor's degree or equivalent experience (3+ years of working healthcare fraud, waste and abuse investigations)
Anticipated Weekly Hours: 40 Time Type: Full-time Pay Range: $46,988.00 - $102,000.00
Benefits:
- Medical, dental, and vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
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