Fraud Investigator

Peraton•,

6d•$66,000 - $106,000•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. 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, overpayment recovery, and other administrative actions. The role involves working with internal resources and external agencies to develop cases and corrective actions, as well as responding to requests for data and support. An investigator uses good judgment and may work independently with minimum supervision and direction, or as part of a team with state and/or federal investigators and other personnel. The investigator handles multiple caseload assignments concurrently, organizes and analyzes complex evidentiary patterns, and 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, and may need to apply federal or state laws. Investigators are expected to research and understand relevant offenses, conduct efficient and effective investigations, and obtain information and evidence by observation, record examination, and interview. They then analyze the results to ascertain if allegations have been corroborated and work with others to determine appropriate steps. As part of an investigation, the investigator will need to prepare correspondence, be objective and accurate, and communicate with others with tact. Investigators may need to react to unplanned situations, be flexible in planning activities, and adopt effective courses of action. As investigators will be working with health privacy information, they also must maintain confidentiality and understand all laws, rules, and regulations concerning health privacy. The role also includes providing training and mentoring on tools/skills used in the investigative process and developing expertise in a variety of tools to assist in investigation development and identification of potential fraud schemes. Ideally, the candidate will be located in Maine, New Hampshire, Vermont, New York, Rhode Island, Connecticut, Massachusetts, Pennsylvania, Delaware, District of Columbia, New Jersey, Maryland, or Northern Virginia.

Requirements

5 years with BS/BA; or 9 years investigative experience with high school diploma
Strong investigative skills
Strong communication and organization skills
Strong PC knowledge and skills
US Citizen
Ability to perform research and draw conclusions
Ability to organize a case file, accurately and thoroughly document all steps taken
Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
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 manage and prioritize workload effectively so that customer metrics are met or exceeded.
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 and/or Medicaid programs 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
Three to five years investigative experience preferred
Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters

Responsibilities

Perform high-level complex investigations of medical professional service providers.
Develop cases for future action, including referral to law enforcement, education, overpayment recovery, and other administrative actions.
Work with internal resources and external agencies to develop cases and corrective actions.
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 relevant offenses being investigated.
Conduct efficient and effective investigations concerning alleged offenses.
Detect or verify suspected violations.
Obtain information and evidence by observation, record examination, and interview.
Analyze the results of the investigation to ascertain if allegations have been corroborated.
Work with others to determine the appropriate steps to address issues.
Prepare correspondence.
Be objective and accurate and communicate with others with tact.
React to unplanned situations, be flexible in planning activities, and adopt effective courses of action.
Maintain confidentiality and understand all laws, rules, and regulations concerning health privacy.
Provide training and mentoring on tools/skills used in the investigative process.
Develop expertise in a variety of tools to assist in the development of investigations and to participate in the identification of potential fraud schemes.
Attend meetings, training, conferences, and perform overnight travel as required.
Appear in court to testify to work findings.