Investigator

Job Description:

• Perform high-level complex Medicare and Medicaid investigations and develop cases for future action, including law enforcement referrals, education, overpayment recovery, and other administrative actions
• Conduct investigations into alleged healthcare fraud, waste, and abuse by researching offenses, reviewing records, performing interviews, and collecting evidence
• Analyze investigative findings to determine whether allegations are substantiated and develop corrective actions or referrals with colleagues and subject matter experts
• Develop, document, and maintain comprehensive case files and update databases and case tracking tools
• Research Medicare and Medicaid claims data and other information to establish policy requirements
• Prepare detailed investigative reports applying federal or state laws, rules, and regulations
• Coordinate with internal teams and external agencies, including law enforcement, legal counsel, CMS, and state or federal investigators
• Conduct background research on suspect providers to identify adverse relationships, sanctions, exclusions, or disqualifying information
• Review and interpret healthcare policies, regulations, and instructions
• Ensure evidence is collected, documented, and safeguarded according to rules of evidence and investigative guidelines
• Analyze claims data to identify fraud, waste, and abuse patterns or anomalies and contribute to fraud scheme detection methodologies
• Respond to law enforcement and client requests for data, documentation, or investigative support
• Review and approve administrative action requests before submission to CMS and provide training and mentoring
• Maintain statistics on submitted administrative actions and maintain template documents
• Conduct on-site visits and in-person interviews when required

Requirements:

• Bachelor degree in business or related field with 5-7 years experience (e.g., law enforcement investigation, statistics, data analysis)
• 6+ years investigative experience in the Healthcare industry
• At least 3 years of experience in benefit integrity investigation/detection or a related field demonstrating expertise in reviewing, analyzing/developing information, and making appropriate decisions
• Knowledge of CMS Medicare Program Integrity Manual, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions
• Strong investigative skills
• Advanced data analysis skills
• Knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS level II and CPT codes
• Utilizes Medicaid and Contractor guidelines for coverage determinations
• Experience reviewing claims for appropriate billing and medical coding requirements, performing medical review, and/or developing fraud cases
• Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) preferred
• Must pass post hire background screening checks
• For remote work, required to have wired and/or wireless internet access
• Ability to obtain security clearance, if required by Client/Contract

Benefits:

• Vacation
• Sick leave
• Paid holidays
• Health insurance
• Dental insurance
• Vision insurance
• Short- and long-term disability
• Life insurance
• Employee assistance plan
• 401(K) retirement plan
• Educational benefits
• Remote work
• Wired and/or wireless internet access required for remote work