Senior Associate, Fraud Investigation

This is a fully remote position, open to applicants in Connecticut, +9 more states.

📋 Description

• Conduct comprehensive and intricate investigations of medical professional service providers.

• Establish cases for referral to law enforcement, educational entities, overpayment recovery, and other administrative processes.

• Collaborate with internal resources and external organizations to formulate cases and corrective measures.

• Address requests for data and provide support.

• Handle multiple caseloads simultaneously.

• Organize and analyze intricate evidentiary patterns.

• Interview witnesses and other relevant individuals to gather statements.

• Complete investigative reports in accordance with applicable regulations, rules, federal and state laws.

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

• Gather information and evidence through observation, record examination, and interviews.

• Analyze the outcomes of investigations to ascertain the credibility of allegations.

• Work collaboratively with others to identify suitable corrective actions.

• Prepare objective and precise correspondence while communicating tactfully.

• Adapt to unforeseen circumstances and modify investigative strategies and actions accordingly.

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

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

• May need to appear in court to testify regarding investigative findings.

⛳️ Requirements

• 2 years of experience with a BS/BA or 6 years of experience with a high school diploma or equivalent.

• Familiarity with Medicare and/or Medicaid programs, including their rules, regulations, policies, and procedures.

• Knowledge and experience in the healthcare sector.

• Excellent investigative abilities.

• Strong communication and organizational skills.

• Proficient PC skills and knowledge.

• US citizenship is mandatory.

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

• Understanding of investigative practices related to healthcare providers is preferred.

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

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

• Ability to perform research and draw logical conclusions.

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

• Ability to present issues of concern and reference regulatory violations or alleged schemes.

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

• Proficient in effective internal and external communication.

• Ability to interpret laws and regulations.

• Capability to handle confidential information responsibly.

• Skill in managing and prioritizing workload efficiently.

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

• Capacity to work independently and as part of a team.

• Willingness to attend meetings, training sessions, and conferences; overnight travel may be required.

• May be required to appear in court and provide testimony regarding work findings.

🏝️ Benefits

• Telework options available from eligible locations.

• Overtime opportunities may be available.

• Shift differentials may be offered.

• Discretionary bonuses may be available.