Senior Special Investigator Unit - The Health Plan

We are searching for a Senior Investigator - Investigative Unit – someone who works well in a fast-paced setting. In this position, you will assist the Director of Controls and Compliance and Special Investigative Unit Manager in conducting investigations into suspected incidents of Fraud, Waste, and Abuse (FWA).  This includes data mining for potential intakes, performing preliminary analysis on provider cases, and working on projects focused on preventing, detecting, and correcting fraud, waste, and abuse. 

Skills & Requirements

• H.S. Diploma or GED with preferred bachelor's degree
• 6 years’ experience in claims examination, adjusting, fraud detection, or investigations preferably in a healthcare environment
• Preferred certification as an Accredited Health Care Fraud Investigator (AHFI) by the National Healthcare Anti-Fraud Association (NHCAA) 

Job Duties & Responsibilities

• Conducts Fraud, Waste and Abuse (FWA) and related compliance investigations.
• Completes detailed and extensive investigations in adherence with organization’s procedures and best practices. Gather evidence and determine potential recoveries.
• Independently develops and executes appropriate investigation strategy for assigned cases. Leads in-depth interviews of participants, witnesses or affected parties.
• Researches and prepares cases for clinical and legal reviews.
• Conducts reviews of flagged claims and suspected FWA, identifying opportunities for improving payment accuracy and preventing FWA.
• Analyzes compliance and FWA cases for root cause, trends, and tracks data to translate findings and develop processes for improvement or investigation.
• Prepares accurate, timely, unbiased, and detailed written reports and case summaries in compliance with corporate standard operating procedures and guidelines documenting investigative results.
• Prepares referrals for preliminary investigations, including Requesting medical records, creating forms, reports and updating logs.
• Facilitates the recovery of inappropriate payments from FWA matters.
• Drafts recoupment letters for FWA findings.
• Supports other investigators in SIU operations.
• Trains SIU Investigator on Investigation procedures.
• Maintains case management log with investigative notes, reports, and summaries.
• Proactively collaborates with line of business personnel to generate referrals.
• Partners with the federal and state agencies on data requests, projects, investigations, and meetings.
• Communicates investigation outcomes to line of business personnel and partners to implement provider and other compliance/ SIU related edits when appropriate.
• Maintains organization’s confidential information in accordance with corporate policies, as well as state and federal laws, rules, and regulations regarding confidentiality. 

Please Note: this is a hybrid position. Onsite/In-office work will be required each week

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