Fraud Investigator – Medicare

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

📋 Description

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

• Create cases for referral to law enforcement, educational bodies, 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.

• Manage multiple caseloads simultaneously.

• Organize and analyze intricate evidentiary patterns.

• Interview witnesses and other involved parties to gather statements.

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

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

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

• Evaluate investigative outcomes to determine the validity of allegations and suggest suitable actions.

• Draft objective and precise correspondence.

• Uphold the confidentiality of health privacy information and comply with relevant laws, rules, and regulations.

• Provide training and guidance on investigative tools and methodologies.

• Cultivate expertise in investigative support tools and identify potential fraud schemes.

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

• Participate in meetings, training sessions, and conferences.

• Testify in court regarding investigative findings when necessary.

⛳️ Requirements

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

• 5 to 6 years of investigative experience.

• Proficient investigative skills.

• Excellent communication and organizational skills.

• Strong computer knowledge and skills.

• US citizenship is mandatory.

• Capability to conduct research and draw informed conclusions.

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

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

• Ability to interpret laws and regulations effectively.

• Capacity to manage confidential materials appropriately.

• Skill in prioritizing workload to meet or exceed customer metrics.

• Ability to work autonomously as well as collaboratively within a team.

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

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

• Familiarity with investigative practices related to healthcare providers.

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

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

• Ability to learn and operate various data systems, equipment, and tools utilized in investigations.

🏝️ Benefits

• Overtime eligibility may be available based on the specific position.

• Shift differential may be available depending on the role.

• Discretionary bonuses may be offered based on the position.

• Opportunities or requirements for overnight travel may exist.