Fraud Investigator – Medicare

This is a fully remote position, open to applicants in Florida, +2 more states.

📋 Description

• Conduct in-depth investigations of medical professional service providers, focusing on complex cases.

• Create case files for referral to law enforcement, educational institutions, overpayment recovery, and other administrative actions.

• Collaborate with internal resources and external organizations to build cases and implement corrective measures.

• Address requests for data and provide support as needed.

• Work autonomously with minimal oversight and guidance.

• Partner with state and/or federal investigators and other relevant personnel.

• Manage multiple caseloads simultaneously.

• Structure and analyze intricate patterns of evidence.

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

• Prepare detailed investigative reports that adhere to relevant program regulations and legal standards.

• Investigate pertinent offenses efficiently to identify or confirm suspected violations.

• Collect evidence and information through observation, examination of records, and interviews.

• Evaluate investigation outcomes to ascertain whether allegations are substantiated and determine the necessary corrective actions.

• Draft objective and precise correspondence.

• Ensure the confidentiality of health privacy information and comply with applicable laws, rules, and regulations.

• Perform site verifications to confirm the operational status of providers.

• Engage in fieldwork monthly, involving approximately 25% travel.

• Testify in court regarding investigative findings when necessary.

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

⛳️ Requirements

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

• Experience in investigative work.

• Excellent communication and organizational skills.

• Proficient knowledge and skills in personal computing.

• Must possess a valid driver's license and be able to rent a vehicle.

• U.S. citizenship is mandatory.

• Capability to perform research and draw informed conclusions.

• Ability to present concerns, highlighting regulatory infractions and alleging fraud schemes against the Government.

• Skill in organizing case files and accurately documenting all actions taken.

• Competence in composing correspondence, reports, and summary letters for referrals.

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

• Proficient in effective communication, both internally and externally.

• Capability to interpret relevant laws and regulations.

• Ability to handle confidential materials appropriately.

• Timely reporting of work activities is essential.

• Must be able to work independently as well as collaboratively within a team.

• Willingness to attend meetings, training, and conferences; overnight travel is required.

• Desirable: Strong background in investigative practices.

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

• Desirable: Knowledge of investigative practices related to healthcare providers.

• Desirable: Familiarity with Medicare program rules, regulations, policies, and procedures.

• Desirable: Experience in evaluating, reviewing, and analyzing medical claims and records.

• Desirable: Ability to learn and utilize various data systems, equipment, and tools pertinent to investigations.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Life insurance coverage.

• Health savings account.

• Short-term and long-term disability insurance.

• Employee assistance program (EAP).

• Parental leave policies.

• 401(k) retirement plan.

• Paid time off (PTO) for vacation purposes.

• Company-paid holidays.

• Eligibility for overtime pay.

• Eligibility for shift differentials.

• Opportunity for discretionary bonuses.

• Telework options available from Florida, South Carolina, or Virginia.