Lead Investigator

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

📋 Description

• Act as the representative of the Special Investigations Unit with federal and state regulatory agencies.

• Oversee regulatory communications and guarantee prompt responses from oversight agencies.

• Detect and track emerging trends in fraud, waste, and abuse.

• Investigate claims, industry sources, and both internal and external data to uncover potential fraud.

• Utilize data analytics platforms to analyze large datasets and pinpoint fraudulent activities, patterns, and billing discrepancies.

• Create and oversee the Annual Program Integrity Fraud, Waste, and Abuse Plan.

• Innovate and implement best practices aligned with growth objectives and regulatory compliance.

• Serve as the Program Integrity liaison with both state and federal agencies.

• Assist in the implementation and monitoring of state-specific regulations for Medicaid and Medicare programs.

• Foster relationships through external fraud associations and industry collaborations.

• Recognize cost-avoidance opportunities via prepayment reviews, provider education, and preventive strategies.

• Guarantee the accuracy of regulatory reporting and address regulatory inquiries.

• Ensure high-quality, high-volume FWA referrals to state partners.

• Lead on-site investigations and provide mentorship to the team.

• Conduct and support intricate investigations.

• Collaborate with data analytics teams and employ RAT-STATS for statistically valid random sampling.

• Oversee investigation turnaround times and the quality of case documentation.

• Generate and trend leads in fraud detection to highlight quality improvement and targeted investigation opportunities.

• Identify trends and patterns using corporate processes, tools, reports, databases, policies, coding guidelines, and regulations.

• Manage and make decisions regarding claims pending investigation.

• Stay informed about state and federal laws, regulations, and provider billing guidelines.

• Prepare and conduct comprehensive, complex interviews.

• Implement and manage provider corrective action plans.

• Engage in meetings with operational, business, legal, and regulatory partners.

• Assist with legal actions, corrective measures, negotiations, recoveries, settlements, and preparation of evidentiary documents.

• Design data analysis strategies for quality enhancements and targeted investigations.

• Monitor media outlets and state and federal press releases for emerging schemes and potential exposures.

• Spearhead information-sharing initiatives and create actionable data analyses.

• Safeguard confidential investigative information.

• Ensure compliance with applicable laws, regulations, contracts, the Corporate Compliance Plan, and the Anti-Fraud Plan.

• Support federal and state regulatory audits.

• Perform additional job-related duties as required.

⛳️ Requirements

• A Bachelor’s Degree or equivalent years of relevant experience in Fraud & Abuse Investigations is essential.

• At least 10 years of experience in Healthcare Fraud, Healthcare data analysis, or Compliance is required.

• Two of the following certifications are required: Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Certified Professional Coder (CPC), or 6 years of coding experience.

• Demonstrated analytical skills in addressing multi-faceted problems.

• Proficient in advanced Microsoft Applications, including Excel, Access, Word, and PowerPoint.

• Preferred experience with SAS and SQL for analytics projects.

• Knowledge and experience with OIG/FBI/MFCU.

• Understanding of inferential statistics.

• Familiarity with descriptive statistical applications and techniques.

• Strong critical listening, thinking, verbal, and written communication skills.

• Effective decision-making and problem-solving abilities.

• Capability to work both independently and collaboratively within a team.

• Knowledge of various Medicaid, Medicare, and managed care plans.

• Extensive understanding of inpatient and outpatient coding standards, billing rules and regulations, and procedure and diagnosis codes including CPT, ICD-10, HCPCS, APC, and DRGs.

• Awareness of value-based reimbursement methodologies.

• Ability to lead analytical initiatives.

• A Master’s Degree is preferred.

• Previous law enforcement experience is preferred.

🏝️ Benefits

• Potential bonus linked to company and individual performance.

• Comprehensive total rewards package offered.

• Occasional travel for meetings, training, and conferences may be necessary.