Fraud and Waste Investigator
About The Position
The Fraud and Waste Professional 2 conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Fraud and Waste Professional 2 coordinates investigation with law enforcement authorities. Assembles evidence and documentation to support successful adjudication, where appropriate. Conducts on-site audits of provider records ensuring appropriateness of billing practices. Prepares complex investigative and audit reports. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
Requirements
- Bachelor's degree
- 2 years of healthcare fraud investigations and auditing experience
- Knowledge of healthcare payment methodologies, claims, submissions, and payments
- Strong organizational, interpersonal, and communication skills
- Inquisitive nature with ability to analyze data to metrics
- Proficiency with MS Word, Excel, Access
- Strong personal and professional ethics
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
- Must have the ability to provide a high speed DSL or cable modem for a home office.
- A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
- Satellite and Wireless Internet service is NOT allowed for this role.
- A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Nice To Haves
- Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI)
- Experience testifying in court
- Understanding of healthcare industry, claims processing, and investigative process development
- Experience in a corporate environment and understanding of business operations
Responsibilities
- Conducts investigations of allegations of fraudulent and abusive practices.
- Coordinates investigation with law enforcement authorities.
- Assembles evidence and documentation to support successful adjudication.
- Conducts on-site audits of provider records ensuring appropriateness of billing practices.
- Prepares complex investigative and audit reports.
Benefits
- Benefits starting day 1 of employment
- Competitive 401k match
- Generous Paid Time Off accrual
- Tuition Reimbursement
- Parent Leave
- Go365 perks for well-being
- medical, dental and vision benefits
- 401(k) retirement savings plan
- time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
- short-term and long-term disability
- life insurance
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
