Fraud Investigator

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

📋 Description

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

• Create 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.

• Address requests for data and provide support.

• Operate independently with minimal oversight as well as part of teams with state and/or federal investigators.

• Juggle multiple case assignments simultaneously.

• Organize and scrutinize complex evidentiary patterns.

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

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

• Investigate relevant offenses and conduct inquiries to identify or confirm suspected violations.

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

• Evaluate investigation outcomes to ascertain the credibility of allegations and suggest appropriate actions.

• Prepare correspondence and summary letters for referrals.

• Uphold objectivity, accuracy, tact, and confidentiality when managing health privacy information.

• Modify investigation plans and respond adeptly to unforeseen circumstances.

• Educate providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups on program safeguard issues.

• Organize and prioritize workload to meet or exceed customer metrics.

⛳️ Requirements

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

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

• Knowledge and experience in the healthcare sector.

• Strong investigative abilities.

• Excellent communication and organizational skills.

• Proficient PC knowledge and skills.

• U.S. citizenship is mandatory.

• Preferred: substantial background in investigations.

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

• Preferred: awareness of investigative practices concerning healthcare providers.

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

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

• Ability to attend meetings, training sessions, and conferences; overnight travel may be necessary.

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

🏝️ Benefits

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

• Eligibility for overtime may be applicable.

• Shift differentials may be applicable.

• Discretionary bonuses may be available.