Fraud Investigator

This is a fully remote position, open to applicants in United States.

📋 Description

• Assist in high-level investigations of medical professional service providers.

• Create cases and reports for law enforcement referrals, educational purposes, overpayment recovery, and other administrative actions.

• Collaborate with fraud investigators and auditors to develop cases, conduct audits, and implement corrective measures.

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

• Respond to inquiries for data and provide necessary support.

• Manage multiple caseload assignments simultaneously.

• Organize and analyze information to support the team's workload.

• Assist in the preparation of complex reports that apply relevant regulations or rules to affected programs.

• Research and comprehend relevant offenses.

• Conduct thorough investigations and audits concerning alleged offenses efficiently and effectively.

• Identify or confirm suspected violations through observation, record examination, and interviews.

• Analyze results from investigations and audits to ascertain whether allegations are substantiated.

• Assist in determining appropriate actions to address identified issues.

• Prepare objective and accurate correspondence while communicating tactfully.

• Adapt to unforeseen situations and adjust investigative activities and strategies as needed.

• Ensure confidentiality of health privacy information while adhering to applicable laws, rules, and regulations.

⛳️ Requirements

• No experience required with a BS/BA, or 4 years of experience with a HS diploma/equivalent.

• Experience in investigative and analytical roles.

• Excellent communication and organizational skills.

• Proficient in PC knowledge and skills.

• US citizenship is required.

• A strong background in investigations or compliance audits is preferred among competitive candidates.

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

• Familiarity with investigative or audit practices concerning healthcare providers is preferred among competitive candidates.

• Knowledge of Medicare and/or Medicaid programs and their relevant rules, regulations, policies, and procedures is preferred among competitive candidates.

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

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

• Ability to conduct research and draw conclusions.

• Ability to document information supporting the investigative/audit workload, articulate concerns, cite regulatory violations, and report schemes or scams aimed at defrauding the Government.

• Ability to organize a case file and accurately document all steps taken.

• Capability to compose correspondence, reports, and referral summary letters.

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

• Effective communication skills, both internally and externally.

• Ability to interpret laws and regulations.

• Capability to handle confidential material appropriately.

• Ability to report work activities promptly.

• Ability to work as a team member under direct supervision to deliver high-quality results.

• Willingness to attend meetings and training conferences; overnight travel may be necessary.

🏝️ Benefits

• Telework is available for those in the Eastern Time Zone.

• Overtime opportunities may be available.

• Shift differentials may be offered.

• Discretionary bonuses may be provided.

• We are an equal opportunity employer, including individuals with disabilities and protected veterans, as well as other characteristics protected by law.