Description

If you are interested in providing consulting and advisory services or supporting contracts, then this operational support position is for you.  The Healthcare Fraud Investigator works as an integral member of a multi-disciplinary team in conducting Medicare and Medicaid investigations. In this position, you will independently perform in-depth reviews and make field level judgments in supporting potential healthcare fraud, waste, and abuse investigations or cases that meet established criteria for referral for administrative action or to law enforcement agencies for criminal or civil action. The Healthcare Fraud Investigator will receive day-to-day directions and instructions from a program director, program integrity manager, lead, or their designees for the work activities on behalf of a client. The Healthcare Fraud Investigator will interact with law enforcement partners at the headquarters, regional, and field office levels to discuss potential fraud, waste, and, abuse and potential referrals.

Requirements

Responsibilities

• Works on investigations and cases assigned by a director, manager, or their designees and meets the required completion time frames and performance metrics.
• Utilizing proactive and reactive leads generated by the team or referrals from partners and stakeholders, works with the team to prioritize complaints for investigation, and then independently investigates each lead by conducting interviews and reviewing data and information to make a potential fraud, waste, and abuse determination.
• Using pre-established external and internal criteria, determines if allegations of potential fraud, waste, and abuse issues merit investigation and/or referral.
• Performs background research by using contract and client data processing systems, third party data sources, and criteria, such as laws, rules, regulations, and manuals, to detect and identify potential fraud, waste, and abuse patterns, schemes, and trends, as well as program vulnerabilities.
• Requests and reviews information from other partners and stakeholders.
• Conducts interviews of victims, witnesses, informants, subject area experts, and targets of investigations.
• Identifies, collects, preserves, analyzes, and summarizes evidence.
• Examines records and verifies the authenticity of data, information, and documents.
• Enters, revises, and updates investigation and case information in the designated case management system(s) within the stipulated time frames required by the client.
• Prepares investigation reports, executive summaries, forms, and other documents in support of investigations or cases referrals to law enforcement or regulatory agencies.
• Utilizes data analysis techniques and analyzes proactive data and information to initiate investigations or make decisions for existing investigations.
• Attends internal and external meetings with or on behalf of clients related to contracts or other work assignments.
• Prioritizes and accomplishes tasks independently with minimal supervision and/or in a team setting to ensure successful implementation of goals and objectives.
• Provides briefings on specific cases or potential fraud, waste, and abuse issues as necessary.
• Participates in the appropriate contract/client training and learning development events including, but not limited to, compliance, HIPAA, ISO and security training programs.

Qualifications

• A Bachelor's Degree in Business Administration or Criminal Justice or related field from an accredited college or university.
• A minimum of 3 years of experience conducting healthcare fraud investigations and supporting special investigations unit and program integrity operations.
• Experience working for a health plan, regulatory government agency, special investigations unit, or program integrity contractor is preferred.
• A pre-employment assessment and background check will be required of any candidate prior to employment with the company.
• Must be authorized to work in the United States and work must be conducted in the United States.

Knowledge and Skills

• Ability to demonstrate an understanding of investigation concepts and methods and apply it to the daily work.
• Must have an understanding of healthcare programs and supply chains, and the governing laws, rules, regulations, and policies.
• Ability to analyze data and reports to identify trends and areas for improvement.
• Excellent written and verbal communication skills.
• Ability to work in a multi-team environment and communicate efficiently and effectively with fellow team members, partners, and stakeholders.
• Ability to present to large or small groups when required.
• Proficient in using the Microsoft Office Professional Suite, including Word, Excel, PowerPoint, and Outlook.
• Outstanding organizational, time management, and interpersonal skills.
• Ability to work in a fast-paced environment.
• Demonstrated commitment to professionalism and ethics.
   

Travel Requirements
Minimal Travel. Travel is reimbursable.

Apply Now
Email a cover letter and resume to: jarias@aridell.com