Fraud Investigator

Summary

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.The Investigator will be responsible for triaging, investigating and resolving instances of healthcare waste and billing errors conducted by the medical profession, insured members or the broker community. You will be utilizing information from claims data analysis, tips, complaints from plan members, the medical community and law enforcement agencies to conduct confidential investigations, document relevant findings and report any illegal activities in accordance with all laws and regulations. The Investigator may also conduct onsite provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation. They will act as a subject matter expert with identifying, communicating and recovering losses as deemed appropriate. Where applicable, they will provide testimonials regarding the investigation. May also complete root cause analysis.Undergraduate degree in the area of Criminal Justice, Health Administration or related field; experience may substitute for an undergraduate degree.1 + years of experience in health care fraud, waste and abuse investigations.Certified Coding Specialist preferred, but not required.Certified Fraud Examiner preferred, but not required.Ability to develop fraud investigations.An intermediate or better level of proficiency in MS Excel and MS Word.Strong verbal and written communication, problem solving, organizational, and analytical skills required.Understanding of Medicare Advantage, Part D laws and regulations preferred.Knowledge of HCPCS, ICD-9CM (ICD-10CM) and CPT required.Knowledge of reviewing medical records preferred.Must be self-motivated, goal oriented and have the ability to work independently to successfully conduct investigations.

Job Description

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.The Investigator will be responsible for triaging, investigating and resolving instances of healthcare waste and billing errors conducted by the medical profession, insured members or the broker community. You will be utilizing information from claims data analysis, tips, complaints from plan members, the medical community and law enforcement agencies to conduct confidential investigations, document relevant findings and report any illegal activities in accordance with all laws and regulations. The Investigator may also conduct onsite provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation. They will act as a subject matter expert with identifying, communicating and recovering losses as deemed appropriate. Where applicable, they will provide testimonials regarding the investigation. May also complete root cause analysis.Undergraduate degree in the area of Criminal Justice, Health Administration or related field; experience may substitute for an undergraduate degree.1 + years of experience in health care fraud, waste and abuse investigations.Certified Coding Specialist preferred, but not required.Certified Fraud Examiner preferred, but not required.Ability to develop fraud investigations.An intermediate or better level of proficiency in MS Excel and MS Word.Strong verbal and written communication, problem solving, organizational, and analytical skills required.Understanding of Medicare Advantage, Part D laws and regulations preferred.Knowledge of HCPCS, ICD-9CM (ICD-10CM) and CPT required.Knowledge of reviewing medical records preferred.Must be self-motivated, goal oriented and have the ability to work independently to successfully conduct investigations.