Fraud Investigator – Medicare

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

📋 Description

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

• Create cases for submission to law enforcement, provider education, recovery of overpayments, and other administrative actions.

• Collaborate with internal teams and external agencies to build cases and implement corrective measures.

• Address requests for data and provide support as needed.

• Manage multiple caseloads simultaneously.

• Organize and analyze intricate evidentiary patterns.

• Conduct interviews and gather statements from witnesses and other relevant individuals.

• Prepare detailed investigative reports while adhering to regulations, rules, and applicable federal or state laws.

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

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

• Evaluate investigation outcomes to ascertain the validity of allegations.

• Collaborate with others to determine appropriate actions to resolve identified issues.

• Draft objective and precise correspondence.

• Ensure confidentiality of health privacy information is maintained.

• Testify in court regarding findings as required.

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

• Participate in meetings, training sessions, and conferences.

⛳️ Requirements

• 5 years of experience with a Bachelor's degree or 9 years with a high school diploma/equivalent.

• Proven investigative experience.

• Exceptional investigative skills.

• Excellent communication and organizational abilities.

• Strong knowledge and skills in PC usage.

• U.S. citizenship is mandatory.

• Capability to conduct research and draw informed conclusions.

• Ability to identify and present issues of concern, citing regulatory breaches and alleging fraudulent schemes against the Government.

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

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

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

• Effective communication skills for both internal and external interactions.

• Ability to interpret laws and regulations accurately.

• Competence in handling sensitive material confidentially.

• Timely reporting of work activities is essential.

• Ability to work independently and collaboratively within a team.

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

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

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

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

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

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

🏝️ Benefits

• Telework options available from Georgia.

• Overtime opportunities may be available.

• Shift differentials may be offered.

• Discretionary bonuses may be awarded.

• Overnight travel is required.