Fraud Investigator

This is a fully remote position, open to applicants in Connecticut, +10 more states.

📋 Description

• Conduct in-depth and sophisticated investigations of medical professional service providers.

• Develop cases for referral to law enforcement, educational institutions, overpayment recovery, and other administrative measures.

• Collaborate with internal resources and external agencies to build cases and implement corrective actions.

• Address requests for data and provide support as needed.

• Operate independently with minimal supervision and guidance.

• Work together with state and federal investigators and other personnel.

• Handle multiple caseloads simultaneously.

• Organize and analyze intricate evidentiary patterns.

• Interview witnesses and other individuals to gather statements.

• Prepare detailed investigative reports in accordance with regulations, rules, and applicable federal or state laws.

• Research pertinent offenses and conduct thorough investigations to identify or confirm suspected violations.

• Gather information and evidence through observation, record review, and interviews.

• Assess investigation outcomes to ascertain whether allegations are substantiated.

• Identify appropriate actions to address recognized issues.

• Draft correspondence and communicate in an objective, accurate, and tactful manner.

• Ensure confidentiality of health privacy information and adhere to relevant laws, rules, and regulations.

• Provide training and mentorship on investigative tools and methodologies.

• Cultivate expertise in tools that support investigations and recognize potential fraud schemes.

• Inform providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups about program safeguard matters.

• Participate in meetings, training, and conferences; overnight travel may be required.

• Testify in court regarding investigative findings when necessary.

⛳️ Requirements

• 5 years of experience with a BS/BA or 9 years of experience with a high school diploma/equivalent.

• 5 to 6 years of investigative experience.

• Strong investigative capabilities.

• Excellent communication and organizational skills.

• Proficient knowledge and skills in PC usage.

• US Citizenship is mandatory.

• Ability to conduct research and draw informed conclusions.

• Capability to organize a case file and meticulously document all actions taken.

• Proficiency in presenting issues of concern, referencing regulatory violations, and alleging schemes or scams aimed at defrauding the Government.

• Competence to write correspondence, reports, and referral summary letters.

• Ability to communicate effectively both internally and externally.

• Skill in interpreting laws and regulations.

• Capability to manage confidential materials.

• Proficiency in managing and prioritizing workloads to meet or exceed customer metrics.

• Ability to educate providers, provider associations, law enforcement, other contractors, and beneficiary advocacy groups on program safeguard issues.

• Ability to work autonomously as well as collaboratively within a team.

• Willingness to attend meetings, training, and conferences; overnight travel is required.

• Ability to appear in court to testify regarding work findings when necessary.

• Desired: Experience in reviewing claims for technical requirements, conducting medical reviews, and/or developing fraud cases.

• Desired: Familiarity with investigative practices related to healthcare providers.

• Desired: Knowledge of Medicare and/or Medicaid programs, including their rules, regulations, policies, and procedures.

• Desired: Background in evaluating, reviewing, and analyzing medical claims and records.

• Desired: Capability to learn and utilize various data systems, equipment, and tools used in investigations.

🏝️ Benefits

• Telework options available.

• Overtime eligibility may be applicable.

• Shift differential may be applicable.

• Discretionary bonuses may be offered.

• Equal opportunity employment, including protections for individuals with disabilities and protected veterans.