Investigator

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

📋 Description

• Conduct advanced and intricate investigations related to Medicare and Medicaid, building cases for subsequent actions such as law enforcement referrals, educational initiatives, overpayment recovery, and other administrative measures.

• Investigate allegations of healthcare fraud, waste, and abuse by researching offenses, examining records, interviewing individuals, and gathering evidence.

• Evaluate investigative outcomes to ascertain the validity of claims and collaborate with colleagues and subject matter experts to formulate corrective measures or referrals.

• Create, document, and uphold thorough case files while updating databases and tracking tools related to case management.

• Investigate Medicare and Medicaid claims data along with other relevant information to clarify policy requirements.

• Compile comprehensive investigative reports in accordance with federal or state laws, regulations, and guidelines.

• Collaborate with internal teams and external agencies, including law enforcement, legal advisors, CMS, and federal or state investigators.

• Perform background research on suspected providers to uncover any adverse relationships, sanctions, exclusions, or disqualifying information.

• Review and interpret healthcare policies, regulations, and directives.

• Ensure the collection, documentation, and protection of evidence comply with evidentiary rules and investigative protocols.

• Analyze claims data to uncover patterns or anomalies indicative of fraud, waste, and abuse, contributing to methodologies for fraud detection.

• Address requests from law enforcement and clients for data, documentation, or investigative assistance.

• Evaluate and approve requests for administrative actions prior to submission to CMS and provide training and mentorship.

• Track statistics on submitted administrative actions and maintain template documents.

• Conduct on-site visits and in-person interviews as necessary.

⛳️ Requirements

• Bachelor’s degree in business or a related field, with 5-7 years of experience (e.g., law enforcement investigation, statistics, data analysis).

• More than 6 years of investigative experience within the healthcare sector.

• A minimum of 3 years of experience in benefit integrity investigation/detection or a similar field, demonstrating proficiency in reviewing, analyzing, and developing information to make sound decisions.

• Familiarity with the CMS Medicare Program Integrity Manual, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions.

• Strong investigative skill set.

• Advanced capabilities in data analysis.

• Understanding of medical terminology, including ICD-9-CM, ICD-10-CM, HCPCS level II, and CPT codes.

• Knowledge of Medicaid and Contractor guidelines for coverage determinations.

• Experience in reviewing claims for correct billing and medical coding standards, conducting medical reviews, and/or developing fraud cases.

• Certification as a Fraud Examiner (CFE) or as an Accredited Health Care Fraud Investigator (AHFI) is preferred.

• Successful completion of post-hire background screening is required.

• For remote positions, access to wired and/or wireless internet is mandatory.

• Eligibility to obtain security clearance, if necessary by Client/Contract.

🏝️ Benefits

• Vacation

• Sick leave

• Paid holidays

• Health insurance

• Dental insurance

• Vision insurance

• Short- and long-term disability

• Life insurance

• Employee assistance plan

• 401(K) retirement plan

• Educational benefits

• Remote work

• Wired and/or wireless internet access required for remote work