Fraud Investigator

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

📋 Description

• Conduct comprehensive and intricate investigations of medical professional service providers.

• Develop cases for referral to law enforcement, as well as for educational purposes, overpayment recovery, and other administrative actions.

• Collaborate with internal resources, external agencies, state and federal investigators, and various personnel.

• Respond to data and support requests effectively.

• Manage multiple caseloads simultaneously.

• Organize and analyze complex patterns of evidence.

• Interview witnesses and other individuals to gather statements.

• Prepare investigative reports in accordance with relevant program regulations, rules, and laws.

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

• Collect information and evidence through observation, document examination, and interviews.

• Analyze investigation outcomes to verify allegations and recommend suitable actions.

• Draft objective and precise correspondence while communicating diplomatically.

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

• Conduct research and derive conclusions.

• Systematically organize case files and document investigative processes accurately and comprehensively.

• Present issues, regulatory breaches, and alleged schemes or scams intended to defraud the Government.

• Create correspondence, reports, and summary letters for referrals.

• Provide education to providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups on program safeguarding issues.

• Prioritize and manage workload to meet or surpass customer metrics.

• Work autonomously as well as collaboratively within a team.

• Participate in meetings, training sessions, and conferences; may require overnight travel.

• Testify in court regarding findings from investigations when necessary.

⛳️ Requirements

• 2 years of experience with a BS/BA; 0 years with an MS/MA; or 6 years with a high school diploma/equivalent.

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

• Knowledge and experience within the healthcare sector.

• Exceptional investigative abilities.

• Strong communication and organizational skills.

• Proficient knowledge and skills in PC usage.

• U.S. citizenship is required.

• A robust background in investigations is preferred.

• Experience in reviewing claims for technical requirements, conducting medical reviews, and/or creating fraud cases is preferred.

• Familiarity with investigative practices concerning healthcare providers is preferred.

• Background in evaluating, reviewing, and analyzing medical claims and records is preferred.

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

• Willingness to attend meetings, training, conferences, and travel overnight as needed.

• May need to appear in court to provide testimony regarding work findings.

🏝️ Benefits

• Telework options available from designated U.S. locations.

• Opportunities for overtime may be available.

• Shift differentials may be applicable.

• Discretionary bonuses may be available.

• Equal opportunity employer, including individuals with disabilities and protected veterans.