Investigations Team Lead

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

📋 Description

• Meet quality targets and manage workload to ensure timely development and resolution of investigations.

• Prepare cases for referral to law enforcement or other relevant authorities.

• Provide mentorship and support to the investigative team.

• Serve as a primary contact for the manager.

• Assist team members in developing workflows.

• Review individual workloads during monthly meetings.

• Aid in prioritization and conduct quality control for team members.

• Oversee the quality of UCM/WMM.

• Track timeliness for case updates and escalate issues to management when necessary.

• Monitor investigation and case progression to ensure the utilization of all available remedies, including suspension, pre-pay reviews, and revocation.

• Guide team members in recognizing previously undetected fraud, waste, or abuse through proactive or reactive research, analysis, and development.

• Collaborate with other designated leads for coverage when required.

⛳️ Requirements

• At least 8 years of experience with a BS/BA or 12 years with a high school diploma or equivalent.

• Relevant investigative experience is essential.

• CFE or AHFI certification is preferred.

• Excellent communication and organizational skills.

• Strong computer knowledge and skills.

• U.S. citizenship is required.

• Familiarity with Medicare requirements, laws, rules, and regulations related to billing for services provided under the Program.

• Experience in claims review, medical review, and/or the development of fraud cases.

• Ability to conduct research and draw informed conclusions.

• Capacity to present issues of concern, citing regulatory violations and alleging schemes or scams intended to defraud the Government.

• Proficient in organizing case files and thoroughly documenting all actions taken.

• Ability to draft correspondence, reports, and referral summary letters.

• Competence in educating providers, provider associations, law enforcement, other contractors, and beneficiary advocacy groups on program safeguard issues.

• Effective internal and external communication skills.

• Ability to interpret laws and regulations.

• Capability to manage confidential information.

• Timely reporting of work activities is essential.

• Ability to work independently and collaboratively within a team to produce high-quality work.

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

• Overnight travel is required.

• Proficient in documenting QC results in WMM according to record type.

• Ability to coordinate with other designated leads for coverage during periods of absence from the office during work hours.

🏝️ Benefits

• Medical insurance.

• Dental insurance.

• Vision insurance.

• Life insurance.

• Health savings account.

• Short-term disability.

• Long-term disability.

• Employee assistance program (EAP).

• Parental leave.

• 401(k) plan.

• Paid time off (PTO) for vacations.

• Company-paid holidays.

• Eligible employees may qualify for overtime.

• Shift differential.

• Discretionary bonus.