Fraud Investigator – Medicare

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

📋 Description

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

• Develop cases for referral to law enforcement, educational institutions, overpayment recovery, and other administrative measures.

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

• Manage multiple caseloads simultaneously.

• Organize and analyze complex patterns of evidence.

• Interview witnesses and other individuals to gather statements.

• Prepare investigative reports in accordance with program regulations, rules, and relevant federal or state laws.

• Research pertinent offenses and conduct thorough investigations to detect or verify suspected violations.

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

• Analyze investigation outcomes and determine suitable corrective measures.

• Draft objective and precise correspondence, reports, and referral summary letters.

• Uphold the confidentiality of health privacy information and adhere to applicable laws, rules, and regulations.

• Conduct site verifications to confirm provider operational status.

• Perform fieldwork monthly, involving approximately 25% travel.

• Appear in court to testify about findings when necessary.

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

• Report work activities promptly.

• Attend meetings, training sessions, and conferences.

⛳️ Requirements

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

• Experience in investigations.

• Excellent communication and organizational skills.

• Proficient PC knowledge and skills.

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

• U.S. citizenship is mandatory.

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

• Familiarity with investigative practices concerning healthcare providers is desirable.

• Knowledge of the Medicare program, including its rules, regulations, policies, and procedures, is desirable.

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

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

🏝️ Benefits

• Medical, dental, and vision coverage.

• Life insurance.

• Health savings account.

• Short- and long-term disability insurance.

• Employee assistance program (EAP).

• Parental leave.

• 401(k) retirement plan.

• Paid time off (PTO) for vacation.

• Company-paid holidays.

• Potential for overtime.

• Shift differential pay.

• Discretionary bonuses.

• Overnight travel required for meetings, training, and conferences.