Summary:

The Investigator, Special Investigations Unit (SIU) is a key contributor to the Plan’s member and provider fraud, waste, and abuse (FWA) detection, investigation, remediation, and prevention efforts.

The Investigator utilizes preliminary data to develop, conduct, resolve, document, and report on tips received, allegations, or data mining output that suggests potentially fraudulent or abusive behavior.

The Investigator’s scope of work may range from independent evaluation of preliminary information to on-site audit to participation in Federal or State prosecution of a case.

Your role in our mission:

• 
  Receives cases triaged to the SIU from sources such as Data Analyst or FWA based on preliminary issue evaluation, and priority.
• Begins case portfolio development based on Data Analyst’s findings; over the course of the investigation, expands portfolio to include such documentation as relevant Plan policies and procedures, member and/or provider publications (e.g., Evidence of Coverage or contracts), medical records and audit findings, interview records, etc.
• Reviews preliminary findings and requests pertinent additional data from the applicable parties including, but not limited to, the Data Analyst, FWA or Network Contracting, Claims, Pharmacy, Provider Relations, Business Integration, and/or Customer Care departments.
• Participates in course of appropriate action based on severity of issue and client exposure.
• Collaborates with FWA, Claims Manager and/or Data Analyst to identify audit sample, either random or based on another approved methodology.
• Conducts investigation including comprehensive review of any and/or all portfolio documentation and State-approved, where required, on-site or desk record review and/or member or provider interviews.
• Creates detailed investigation report, including follow-up, remedial action, or recommendations, per department protocol and presents to department management.
• Drafts preliminary investigation results for submission to provider or response to member.
• Drafts Corrective Action Plan, where appropriate.
• Coordinates with Client, Claims, Business Operations, Contracting, and/or Compliance when remedial actions such as pre-payment review, payment suspension, overpayment recovery, etc. dictate.
• Updates department database at prescribed intervals and per department standards.
• As requested, participates in internal and/or external FWA-related information sharing sessions which may include receiving and providing secure data pursuant to contractual requirements.
• Prepares summary and/or detailed reports on investigation findings for referral to Federal and state agencies which may include but are not limited to the state Medicaid agency, Medicaid Fraud Control Units, the Attorney General’s Office, the Department of Insurance, and local law enforcement.
• Collaborates with department management on the data mining function including, but not limited to, specific activities and output necessary to support Investigator’s activities.
• Meets all production deadlines.
• Ensures accuracy and quality of work product by adhering to department’s data validation guidelines.
• Maintain current knowledge of industry standards including Medicare, Medicaid and OIG used in fraud prevention and detection

What we're looking for:

• 
  Demonstrated proficiency with Microsoft Office products
• Time management skills necessary to meet established deadlines in a fast-paced environment, including the ability to re-prioritize tasks as workload and time constraints dictate
• Strong verbal and written communication skills with the ability to clearly articulate thoughts, ideas, processes, and requirements to both internal and external audiences and in potentially contentious situations
• Attention to detail with excellent proof reading and editing skills
• Customer service skills with the ability to interact professionally and effectively with a wide variety of providers, third party payers, and staff from all departments within and outside the Plan
• Organization and analytical skills necessary to aggregate potentially disparate information from multiple sources
• Strong problem-solving skills, including with the ability to determine root causes and to define workable solutions
• Ability to weigh alternatives and select the most appropriate course of action, given the individual circumstances of a case
• Creative thinking skills that allow one to ask the bigger-picture questions that lead to future improvements/gains
• Proven ability to maintain objectivity and the utmost confidentiality

Qualifications:

• 
  Bachelor’s degree in Health Information Management, Health Care Administration, Other Clinical Field, Public Health, Criminal Justice, Law Enforcement, or other related field; an equivalent combination of education, training, and experience will be considered
• Advanced degree in an above noted area preferred

EXPERIENCE:

(Must meet at least two criteria)

• Previous SIU experience with an insurance carrier or investigative firm required
• Five to seven years’ experience in a health care payer setting preferred
• Minimum of four years’ experience in a health care fraud control setting

Certification/Conditions of Employment:

• National Health Care Anti-Fraud Association certification (AHFI), Certified Fraud Examiner (CFE), or America’s Health Insurance Plans Health Care Anti-Fraud Associate (HCAFA) designation is strongly preferred.