Fraud Investigator

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

📋 Description

• Conduct comprehensive, high-level investigations of medical professional service providers.

• Build cases for law enforcement referrals, education, overpayment recovery, and other administrative actions.

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

• Respond to data requests and provide necessary support.

• Manage several concurrent caseloads effectively.

• Organize and analyze intricate patterns of evidence.

• Interview witnesses and other involved parties to gather statements.

• Produce investigative reports that adhere to relevant program regulations, rules, and laws.

• Research pertinent offenses and investigate alleged violations to identify or confirm suspected infractions.

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

• Analyze investigation outcomes to ascertain whether allegations are substantiated.

• Determine suitable corrective actions in collaboration with stakeholders.

• Draft correspondence and referral summary letters.

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

• Adapt to unforeseen circumstances and modify investigative plans as needed.

• Provide training and mentorship on investigative tools and techniques.

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

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

• Attend meetings, training sessions, and conferences; overnight travel may be required.

• Possibly testify in court regarding the findings of investigations.

⛳️ Requirements

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

• Three to five years of investigative experience.

• Excellent investigative skills.

• Strong communication and organizational abilities.

• Proficient in PC knowledge and skills.

• US citizenship is mandatory.

• Capability to perform research and draw informed conclusions.

• Ability to organize case files and accurately document all actions taken.

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

• Capacity to interpret laws and regulations.

• Ability to handle confidential information appropriately.

• Skill in managing and prioritizing workload effectively.

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

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

• May be required to appear in court to provide testimony.

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

• Knowledge of investigative practices related to healthcare providers is preferred.

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

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

• Ability to learn and operate various data systems, equipment, and tools used in investigations is preferred.

🏝️ Benefits

• Potential eligibility for overtime pay.

• Potential eligibility for shift differentials.

• Potential eligibility for discretionary bonuses.

• Telework arrangements available.

• Opportunities for training and mentoring.