Fraud Investigator

Peraton•,

1d•$51,000 - $82,000•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 Fraud Investigator 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. Investigators use 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. They may 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 investigation results to ascertain if allegations are 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 must also react to unplanned situations, be flexible in planning activities, and adopt effective courses of action. Due to working with health privacy information, maintaining confidentiality and understanding all laws, rules, and regulations concerning health privacy is essential. Telework is available from Maine, New Hampshire, Vermont, New York, Rhode Island, Connecticut, Massachusetts, Pennsylvania, Delaware, District of Columbia, New Jersey, Maryland, and Northern Virginia.

Requirements

2 years with BS/BA or 6 years with a HS Diploma/equivalent
Knowledge of Medicare and/or Medicaid programs and the rules, regulations, policies, and procedures
Knowledge and experience in the healthcare industry
Strong investigative skills
Strong communication and organization skills
Strong PC knowledge and skills
US citizenship is required

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
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

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 investigation results to ascertain if allegations have been corroborated.
Work with others to determine the appropriate steps to address issues.
Prepare correspondence.
Be objective and accurate.
Communicate with others with tact.
React to unplanned situations.
Be flexible in planning activities.
Adopt effective courses of action.
Maintain confidentiality of health privacy information.
Understand all laws, rules, and regulations concerning health privacy.
Perform research and draw conclusions.
Organize a case file, accurately and thoroughly document all steps taken.
Present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government.
Compose correspondence, reports, and referral summary letters.
Communicate effectively, internally and externally.
Interpret laws and regulations.
Handle confidential material.
Manage and prioritize workload effectively so that customer metrics are met or exceeded.
Educate providers, provider associations, law enforcement, other contractors, and beneficiary advocacy groups on program safeguard matters.
Work independently and as a member of a team to deliver high-quality work.
Attend meetings, training, conferences.
Perform overnight travel as required.
Appear in court to testify about work findings.