Special Investigation Unit Investigator

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Conduct investigations into fraud, waste, and abuse utilizing referrals, claims data, medical records, interviews, data analysis, and various investigative tools.

• Analyze, document, and preserve records of investigative activities, findings, recommendations, and outcomes.

• Examine claims, medical records, provider billing practices, enrollment data, financial documentation, and other relevant materials for potential fraud, waste, abuse, overpayments, or compliance issues.

• Generate investigative reports, case summaries, referrals, and accompanying documentation for internal stakeholders, regulatory bodies, law enforcement agencies, and other authorized entities.

• Collaborate with business partners, compliance teams, legal departments, provider and payment integrity teams, as well as external organizations.

• Assist with corrective measures, recoveries, audits, identification and recovery of overpayments, regulatory responses, special projects, and program integrity initiatives.

• Track new fraud schemes, billing anomalies, and risks within healthcare programs, recommending suitable actions.

• Facilitate case progression through onsite audits, visits, drive-by activities, and interviews.

• Adhere to all policies and standards, performing additional duties as assigned.

⛳️ Requirements

• Bachelor's degree in Business, Criminal Justice, Healthcare Administration, Public Health, or a related field; or equivalent professional experience.

• An Associate's or Bachelor's degree in criminal justice or a similar field; or prior employment as an investigator in the MMCO's Special Investigations Unit (SIU) before the effective date of this SubPart.

• A minimum of five (5) years of experience in the healthcare sector focusing on fraud, waste, and abuse investigations and audits, or five years in insurance claims investigations, or professional investigative experience with law enforcement, or seven years in professional investigations related to economic or insurance matters.

• Preferred experience in analyzing healthcare claims, medical records, billing and coding documentation, provider data, financial information, or related records to aid investigations and case development.

• Preferred certifications include AHFI, CFE, CPC, CPMA, or other relevant investigative, auditing, or compliance credentials.

• Compliance with relevant federal and state regulations, contractual obligations, privacy standards, investigative protocols, and organizational policies and procedures.

🏝️ Benefits

• Health insurance

• 401K

• Stock purchase plans

• Tuition reimbursement

• Paid time off plus holidays

• Flexible working arrangements with options for remote, hybrid, field, or office schedules