Fraud Investigator – Medicare

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

📋 Description

• Conduct sophisticated and in-depth investigations concerning medical professional service providers.

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

• Collaborate with internal teams and external organizations to build cases and implement corrective actions.

• Address data requests and provide necessary support.

• Manage multiple caseloads simultaneously.

• Organize and evaluate intricate evidentiary patterns.

• Interview and gather statements from witnesses and relevant individuals.

• Draft comprehensive investigative reports while applying applicable regulations or rules to the relevant programs.

• Utilize federal or state laws as necessary.

• Investigate and comprehend pertinent offenses.

• Execute investigations related to alleged offenses and identify or confirm suspected violations.

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

• Analyze investigation outcomes to assess whether allegations are substantiated.

• Collaborate with others to determine appropriate actions for addressing identified issues.

• Prepare correspondence and communicate in a clear, accurate, and tactful manner.

• Safeguard the confidentiality of health privacy information, adhering to relevant laws, rules, and regulations.

• Appear in court to testify regarding findings when necessary.

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

⛳️ Requirements

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

• Experience in investigations.

• Exceptional investigative skills.

• Strong communication and organizational abilities.

• Proficient in PC usage and skills.

• US citizenship is mandatory.

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

• Understanding of investigative practices pertaining to healthcare providers.

• Familiarity with the Medicare program and its rules, regulations, policies, and procedures.

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

• Capability to learn and utilize various data systems, equipment, and tools relevant to investigations.

• Skill in conducting research and drawing informed conclusions.

• Ability to articulate issues of concern, citing regulatory infractions, and alleging schemes or scams aimed at defrauding the government.

• Proficient in organizing case files and meticulously documenting all undertaken steps.

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

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

• Effective communication skills for both internal and external interactions.

• Ability to interpret laws and regulations.

• Capability to handle confidential information.

• Timely reporting of work activities.

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

• Willingness to attend meetings, training sessions, and conferences.

• Overnight travel is required.

🏝️ Benefits

• Telework options available for individuals located in the Atlanta, GA area or South Carolina.

• Employees may qualify for overtime, shift differentials, and discretionary bonuses in addition to their base salary.

• Equal opportunity employer, inclusive of individuals with disabilities and protected veterans, or any other characteristics safeguarded by law.