Fraud Investigator – Medicare

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

📋 Description

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

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

• Collaborate with both internal resources and external agencies to formulate cases and corrective measures.

• Address data requests and provide support as needed.

• Manage multiple caseloads simultaneously.

• Organize and analyze complex evidentiary patterns.

• Interview witnesses and other individuals to gather statements.

• Produce detailed investigative reports in accordance with applicable regulations, rules, and laws.

• Investigate relevant offenses and conduct inquiries to identify or confirm suspected violations.

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

• Assess investigation outcomes and identify suitable corrective actions.

• Draft correspondence and referral summary letters.

• Uphold confidentiality of health privacy information.

• Conduct site verifications to confirm provider operational status.

• Provide testimony in court regarding investigative findings when necessary.

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

• Report work activities promptly.

• Participate in meetings, training sessions, and conferences.

⛳️ Requirements

• 5 years of experience with a BS/BA; 3 years with an MS/MA; 0 years with a PhD.

• Prior investigative experience is essential.

• Strong investigative abilities are required.

• Excellent communication and organizational skills are necessary.

• Proficiency in PC knowledge and skills is needed.

• U.S. citizenship is mandatory.

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

• Familiarity with investigative practices related to healthcare providers is required.

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

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

• Capability to learn and utilize various data systems, equipment, and tools employed in investigations is important.

🏝️ Benefits

• Telework opportunities available from South Florida.

• Overnight travel may be necessary.

• Employees might qualify for overtime compensation.

• Employees may be eligible for shift differentials.

• Employees might receive a discretionary bonus.