Fraud Investigation, Senior Associate

Peraton•,

4d•$51,000 - $82,000

About The Position

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, and reduce fraud, waste, and abuse, and to make referrals for recovery. The Fraud Investigator performs complex investigations of medical professional service providers and develops cases for potential law enforcement referral, education, overpayment recovery, and other administrative actions. The role involves working with internal resources and external agencies to develop cases and corrective actions and respond to requests for data and support. The investigator exercises judgment and may work independently with minimal supervision, as well as collaboratively with state and federal investigators and other personnel. The role manages concurrent caseloads, analyzes complex evidentiary patterns, interviews witnesses and others, and prepares investigative reports applying relevant program rules and regulations and, where necessary, federal or state laws. Investigators research relevant offenses, conduct effective investigations, obtain information and evidence through observation, record examination, and interviews, and analyze results to determine whether allegations are corroborated and what actions should follow. The position also involves preparing correspondence, communicating objectively, accurately, and tactfully, adapting plans to unanticipated situations, and maintaining the confidentiality of health privacy information in accordance with applicable laws, rules, and regulations. Telework is available from Maine, New Hampshire, Vermont, New York, Rhode Island, Connecticut, Massachusetts, Pennsylvania, Delaware, the District of Columbia, New Jersey, Maryland, and Northern Virginia. Overnight travel is required for meetings, training, and conferences. The incumbent may be required to testify in court about work findings.

Requirements

At least 2 years of experience with a BS/BA, or 6 years of experience with a high school diploma or equivalent.
Knowledge of Medicare and/or Medicaid programs, including their rules, regulations, policies, and procedures.
Knowledge and experience in the healthcare industry.
Strong investigative skills.
Strong communication and organizational skills.
Strong PC knowledge and skills.
U.S. citizenship required.
Ability to research and draw conclusions.
Ability to organize case files and accurately and thoroughly document investigative steps.
Ability to compose correspondence, reports, and referral summary letters.
Ability to communicate effectively internally and externally.
Ability to interpret laws and regulations.
Ability to handle confidential material.
Ability to work independently and as part of a team.
Ability to manage and prioritize workload effectively to meet customer metrics.
Ability to attend meetings, training, and conferences, with overnight travel required.
May be required to appear in court to testify about work findings.

Nice To Haves

Strong background in investigations.
Experience reviewing claims for technical requirements, performing medical review, and/or developing fraud cases.
Knowledge of investigative practices regarding healthcare providers.
Background evaluating, reviewing, and analyzing medical claims and records.
Ability to learn and operate a variety of data systems, equipment, and tools used in investigations.

Responsibilities

Conduct complex investigations of medical professional service providers and develop cases for law enforcement referral, education, overpayment recovery, or other administrative actions.
Work with internal resources, external agencies, and state or federal investigators to develop cases and corrective actions and respond to requests for data and support.
Manage multiple caseload assignments concurrently and organize and analyze complex evidentiary patterns.
Interview witnesses and others and obtain statements.
Research relevant offenses and conduct efficient investigations to detect or verify suspected violations.
Obtain information and evidence through observation, record examination, and interviews.
Analyze investigative results to assess whether allegations are corroborated and collaborate on appropriate next steps.
Prepare complex investigative reports applying relevant program regulations or rules and, when necessary, federal or state laws.
Prepare correspondence and communicate objectively, accurately, and tactfully.
Maintain confidentiality and comply with laws, rules, and regulations concerning health privacy information.
Organize case files and accurately document investigative steps.
Present issues of concern, cite regulatory violations, and describe alleged schemes or scams to defraud the Government.
Compose reports and referral summary letters.
Educate providers, provider associations, law enforcement, other contractors, and beneficiary advocacy groups on program safeguard matters.
Manage and prioritize workload to meet or exceed customer metrics.
Attend meetings, training, and conferences; travel overnight as required.
Appear in court to testify about work findings when required.