Fraud Investigator - Medicare

Peraton•Home, GA

13d•Remote

About The Position

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse. Telework available from Atlanta, GA area or South Carolina. We are looking to add a Fraud Investigator to our SGS team of talented professionals. The position is expected to perform high level complex investigations of medical professional service providers and develop cases for future action, including referral to law enforcement, education, over payment recovery and other administrative actions. Will work with internal resources and external agencies to develop cases and corrective actions as well as respond to requests for data and support. An investigator uses good judgment and may work independently with minimum supervision and direction. The investigator also may work as part of a team as there may be times when the investigator needs to work with state and/or federal investigators and other personnel. An investigator handles multiple caseload assignments concurrently; organizes and analyzes complex evidentiary patterns; interviews and obtains statements from witnesses and others. Investigators may also be required to complete complex investigative reports that apply regulations or rules to the program(s) affected by the behavior being investigated. There may also be times when the investigator will need to apply federal or state laws. Investigators are expected to research and understand the relevant offenses being investigated; conduct efficient and effective investigations concerning those alleged offenses and detect or verify suspected violations; obtain information and evidence by observation, record examination, and interview. Investigators then analyze the results of the investigation to ascertain if the allegations have been corroborated and work with others to determine the appropriate steps that need to be taken to address the issues. As part of an investigation, the investigator will need to prepare correspondence; be objective and accurate and communicate with others with tact. There may be times when investigators need to react to unplanned situations, be flexible in planning their activities and adopt effective courses of action. As investigators will be working with health privacy information, they also must maintain confidentiality and understand all the laws, rules and regulations concerning health privacy.

Requirements

5 years with BS/BA; or 9 years with a HS Diploma.
Investigative experience
Strong investigative skills
Strong communication and organization skills
Strong PC knowledge and skills
US. citizenship required
Ability to perform research and draw conclusions
Ability to interpret laws and regulations
Ability to handle confidential material.
Ability to work independently and as a member of a team to deliver high quality work.

Nice To Haves

Strong background in investigations.
Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
Knowledge of investigative practices regarding healthcare providers.
Knowledge of Medicare program and the rules, regulations, policies and procedures
Background in evaluating, reviewing and analyzing medical claims and records
Ability to learn and operate a variety of data systems, equipment and tools used in investigations
Ability to compose correspondence, reports and referral summary letters
Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters
Ability to communicate effectively, internally and externally

Responsibilities

Perform high level complex investigations of medical professional service providers and develop cases for future action, including referral to law enforcement, education, over payment recovery and other administrative actions.
Work with internal resources and external agencies to develop cases and corrective actions as well as respond to requests for data and support.
Handle multiple caseload assignments concurrently.
Organize and analyze complex evidentiary patterns.
Interview and obtain statements from witnesses and others.
Complete complex investigative reports that apply regulations or rules to the program(s) affected by the behavior being investigated.
Apply federal or state laws.
Research and understand the relevant offenses being investigated.
Conduct efficient and effective investigations concerning those alleged offenses and detect or verify suspected violations.
Obtain information and evidence by observation, record examination, and interview.
Analyze the results of the investigation to ascertain if the allegations have been corroborated and work with others to determine the appropriate steps that need to be taken to address the issues.
Prepare correspondence.
React to unplanned situations, be flexible in planning their activities and adopt effective courses of action.
Maintain confidentiality and understand all the laws, rules and regulations concerning health privacy.
Appear in court to testify about work findings.
Present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government.
Organize a case file, accurately and thoroughly document all steps taken.
Compose correspondence, reports and referral summary letters.
Educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters.
Report work activity on a timely basis.
Work independently and as a member of a team to deliver high quality work.
Attend meetings, training, and conferences.