Fraud Investigator

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

📋 Description

• Conduct in-depth and intricate investigations of providers offering medical professional services.

• Prepare cases for referral to law enforcement, educational entities, overpayment recovery, and other administrative actions.

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

• Respond to data requests and provide necessary support.

• Operate independently with minimal supervision and guidance.

• Cooperate with state and federal investigators and other personnel.

• Manage multiple caseloads simultaneously.

• Systematically organize and analyze complex patterns of evidence.

• Conduct interviews with witnesses and other individuals to obtain statements.

• Produce detailed investigative reports that adhere to program regulations, rules, and relevant federal or state laws.

• Investigate relevant offenses to detect or confirm suspected violations.

• Gather information and evidence through observation, examination of records, and interviews.

• Evaluate investigation outcomes to assess whether allegations are supported.

• Identify appropriate actions to rectify recognized issues.

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

• Respond to unforeseen circumstances and adjust investigative plans accordingly.

• Uphold confidentiality regarding health privacy information and adhere to applicable laws, rules, and regulations.

• Provide training and mentorship on investigative tools and methodologies.

• Cultivate expertise in tools that assist investigations and identify potential fraud schemes.

• Participate in meetings, training sessions, and conferences; travel overnight as necessary.

• May be required to testify in court regarding investigative findings.

⛳️ Requirements

• A minimum of 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.

• Excellent investigative skills.

• Strong communication and organizational abilities.

• Proficient knowledge and skills in PC usage.

• US Citizenship is mandatory.

• Capability to conduct research and draw informed conclusions.

• Skill in organizing case files and accurately documenting all actions taken.

• Ability to articulate issues of concern and reference regulatory violations.

• Proficiency in composing correspondence, reports, and referral summary letters.

• Effective internal and external communication skills.

• Competence in interpreting laws and regulations.

• Ability to manage confidential materials.

• Skill in managing and prioritizing workload effectively.

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

• Ability to work autonomously as well as part of a team.

• Willingness to attend meetings, training sessions, and conferences.

• Ability to travel overnight.

• May need to testify in court regarding work findings.

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

• Preferred: Knowledge of investigative practices related to healthcare providers.

• Preferred: Familiarity with Medicare and/or Medicaid programs and associated rules, regulations, policies, and procedures.

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

• Preferred: Ability to learn and utilize data systems, equipment, and tools used in investigations.

🏝️ Benefits

• Eligibility for overtime may apply.

• Shift differentials may be applicable.

• Discretionary bonuses could be available.

• Opportunities for telework arrangements.

• Access to training and mentoring programs.

• Potential for overnight travel opportunities.