Fraud Investigatior - Medicare

Peraton•Home, GA

4d•Remote

About The Position

SafeGuard Services (SGS), a subsidiary of Peraton, conducts data analysis, investigations, and medical reviews 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, or other administrative action. The role works with internal resources and external agencies to develop cases and corrective actions and respond to requests for data and support. Investigators manage concurrent caseloads, organize and analyze complex evidence, interview witnesses, obtain statements, and prepare detailed investigative reports applying relevant program rules and regulations and, when necessary, federal or state laws. They research alleged offenses, gather information through observation, record examination, and interviews, and analyze findings to determine whether allegations are corroborated and what action is appropriate. The position also includes preparing correspondence, communicating tactfully and accurately, maintaining confidentiality of health privacy information, and conducting site verifications of provider operational status. Investigators may work independently with minimal supervision or as part of a team with state and federal investigators and other personnel. Telework is available from South Florida (preferred) and Georgia. Overnight travel is required, and the position may require appearing in court to testify about work findings.

Requirements

At least 5 years of experience with a BS/BA, or 9 years of experience with a high school diploma or equivalent.
Solid investigative experience.
Strong communication and organizational skills.
Strong PC knowledge and skills.
U.S. citizenship required.
Ability to research information and draw conclusions.
Ability to identify and present issues of concern, citing regulatory violations and alleged schemes or scams to defraud the government.
Ability to organize case files and accurately and thoroughly document work performed.
Ability to compose correspondence, reports, and referral summary letters.
Ability to interpret laws and regulations and handle confidential material.
Ability to work independently and as part of a team.
Ability to attend meetings, training, and conferences, with overnight travel required.

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.
Knowledge of the Medicare program and its rules, regulations, policies, and procedures.
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 referral to law enforcement, provider education, overpayment recovery, or other administrative actions.
Work with internal resources and external agencies to develop cases and corrective actions and respond to requests for data and support.
Manage multiple caseload assignments concurrently; organize and analyze complex evidence; interview witnesses and other relevant individuals; and obtain statements.
Research relevant alleged offenses and conduct efficient investigations to detect or verify suspected violations.
Obtain information and evidence through observation, record examination, and interviews; analyze results to determine whether allegations are corroborated and help determine appropriate follow-up actions.
Prepare complex investigative reports applying relevant program rules and regulations and, when necessary, federal or state laws.
Prepare correspondence, reports, and referral summary letters, and document investigative steps accurately and thoroughly.
Conduct site verifications to confirm a provider’s operational status.
Educate providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups on program safeguard matters.
Communicate effectively and tactfully with internal and external parties and maintain confidentiality of health privacy information.
Report work activity on a timely basis and work independently or as a team member to deliver high-quality work.
Attend meetings, training, and conferences; travel overnight as required; and, when required, appear in court to testify about work findings.