Fraud Investigator - Medicare

Peraton•,

1d•$66,000 - $106,000•Hybrid

About The Position

SafeGuard Services (SGS), a Peraton subsidiary, conducts data analysis, investigations, and medical reviews to detect, prevent, deter, and reduce fraud, waste, and abuse, and to support referrals and recovery. The Fraud Investigator performs complex investigations of medical professional service providers and develops cases for possible law enforcement referral, provider education, overpayment recovery, or other administrative action. The investigator works with internal resources and external agencies, either independently with minimal supervision or as part of a team. The role manages multiple caseloads, analyzes complex evidence, interviews witnesses, examines records, and researches suspected offenses. Investigators determine whether allegations are supported, prepare investigative reports and correspondence, apply applicable program rules and regulations and, when needed, federal or state laws, and work with others to identify appropriate corrective actions. The role also involves educating providers and other stakeholders about program safeguards and maintaining the confidentiality of health information. The investigator conducts site verifications to confirm provider operational status and may perform field work monthly. The position estimates travel at 25%, including required overnight travel. Telework is available from Florida, South Carolina, or Virginia. The incumbent may be required to testify in court.

Requirements

Five years of experience with a bachelor’s degree, or nine years of experience with a high school diploma or equivalent.
Investigative experience.
Strong communication and organization skills.
Strong PC knowledge and skills.
Ability to rent a car and possess a valid driver’s license.
U.S. citizenship.
Ability to research and draw conclusions, organize and document case files, compose correspondence and reports, interpret laws and regulations, and handle confidential material.
Ability to work independently and as a team member and communicate effectively internally and externally.

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 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 action.
Work with internal resources, external agencies, state and federal investigators, and other personnel 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, obtain statements, examine records, conduct observations, and gather information and evidence.
Research relevant offenses and conduct efficient investigations to detect or verify suspected violations.
Analyze investigative results to determine whether allegations are corroborated and coordinate appropriate actions to address identified issues.
Prepare complex investigative reports applying relevant program rules, regulations, and, when applicable, federal or state laws.
Prepare correspondence, case files, documentation, reports, and referral summary letters accurately and thoroughly.
Conduct site verifications to confirm a provider’s operational status and perform field work as required.
Educate providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups on program safeguard matters.
Maintain confidentiality and comply with laws, rules, and regulations concerning health privacy.
Report work activity promptly, communicate tactfully and effectively, and respond flexibly to unplanned situations.
Attend meetings, training, and conferences, including overnight travel when required.
Appear in court to testify about work findings when required.