Fraud Investigator Associate

This is a fully remote position, open to applicants in Connecticut, +9 more states.

📋 Description

• Conduct entry-level investigations and audits related to fraud under the close guidance of a team manager or lead.

• Assist in the intricate investigations involving providers of medical professional services.

• Create cases and reports intended for referrals to law enforcement, educational purposes, overpayment recovery, and other administrative measures.

• Collaborate with internal teams, external agencies, state and federal investigators, and other relevant personnel.

• Manage multiple caseloads simultaneously.

• Organize and analyze information that supports team audits and investigations.

• Aid in generating complex reports that adhere to program regulations and guidelines.

• Research pertinent offenses and conduct thorough investigations and audits.

• Identify or confirm suspected violations through observation, examination of records, and interviews.

• Evaluate investigation and audit findings to ascertain if allegations are substantiated.

• Assist in identifying suitable corrective measures.

• Draft objective and precise correspondence and communicate with tact.

• Safeguard the confidentiality of health information and adhere to relevant laws, rules, and regulations.

⛳️ Requirements

• No experience required with a BS/BA degree, or 4 years of experience with a high school diploma or equivalent.

• Experience in investigative and analytical roles.

• Excellent communication and organizational skills.

• Proficient in PC usage and skills.

• Must be a U.S. citizen.

• A strong background in investigations or compliance audits is preferred for highly competitive candidates.

• Experience in reviewing claims for technical standards, performing medical reviews, and/or developing fraud cases and recognizing overpayments.

• Familiarity with investigative or audit practices related to healthcare providers.

• Awareness of Medicare and/or Medicaid programs along with associated rules, regulations, policies, and procedures.

• Experience in evaluating, reviewing, and analyzing medical claims and records.

• Capability to learn and utilize data systems, equipment, and tools applicable in investigations.

• Ability to conduct research and derive conclusions.

• Skill in documenting investigative and audit information and recognizing regulatory violations or suspected fraud schemes.

• Competency in organizing case files and accurately recording all actions taken.

• Proficiency in drafting correspondence, reports, and summary letters for referrals.

• Ability to educate providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups.

• Effective communication skills both internally and externally.

• Ability to interpret laws and regulations.

• Capability to manage confidential materials.

• Timely reporting of work activities.

• Ability to work under direct supervision as part of a team.

• Willingness to attend meetings and training conferences; overnight travel may be necessary.

🏝️ Benefits

• Telework options available from the NE UPIC jurisdiction.

• Eligibility for overtime may apply.

• Shift differentials may be offered.

• Potential for discretionary bonuses.

• Opportunities to attend training conferences.

• Requirements for overnight travel may arise.