Fraud, Waste & Abuse Investigator

Viva Health•Birmingham, AL

About The Position

The Fraud, Waste & Abuse (FWA) Investigator will work with the Compliance department leadership to investigate, respond to, and report on potential FWA. This position is responsible for creating, tracking, and analyzing reports to detect and prevent FWA. This individual will stay abreast of current FWA issues facing health plans, design and document FWA processes, lead/participate in investigations, and make recommendations that will positively impact operational effectiveness.

Requirements

Bachelor’s degree in Business Administration, Law Enforcement, Law, Management Information Systems, Health Information Management, or related field
4 years’ experience in a position gathering, analyzing, and presenting data, findings, and recommendations
Accredited Healthcare Fraud Investigator and/or Certified Fraud Examiner or ability to obtain certification within first year
Knowledge of database query tools such as Crystal Reports, MS Access, and MSSQL
Excellent analytical skills for trending, forecasting, and summarizing large datasets
Possess a high degree of discretion and ability to maintain confidentiality
Ability to adapt to ever changing business situations quickly and accurately
Ability to aggregate and present complex information or data through appropriate data visualization to all levels of the organization
Excellent written and oral communication skills

Nice To Haves

Experience in FWA in a health plan or banking industry is strongly preferred
Project Management Certification (PMP)

Responsibilities

Ensure adequate FWA policies, procedures, and internal controls are developed, implemented, and maintained.
Create reports and utilize vendor and other available reports to monitor and detect suspected FWA.
Perform oversight of FWA vendor activity.
Stay abreast of current FWA trends/areas of concern by participating in FWA workgroups, reading trade journals, attending FWA webinars or conferences as requested, and networking with other FWA experts.
Conduct data analysis and timely, thorough, and accurate investigations of cases assigned to identify and then confirm or deny suspected FWA. This includes developing written communications, holding face-to-face or telephonic meetings, and working with legal counsel as needed.
Maintain thorough documentation of all FWA activity.
Work with other departments and the Compliance department leaders to investigate FWA and ensure corrective actions related to FWA are implemented, including any notices to third parties such as Department of Insurance (DOI) or Centers for Medicare & Medicaid Services (CMS) that may be required.
Work with the Provider Relations department to develop and conduct provider education.
Demonstrate a high level of independence in case investigation and resolution.
Lead recovery efforts for identified FWA where applicable.
Present findings to healthcare providers and negotiate resolution of issues.
Support a management decision to pursue criminal, civil, or other recovery action regarding fraud, waste, and/or abuse.
Coordinate with Federal, State, and Local law enforcement agencies as well as the DOI and Medical Board Investigators (MBI) as necessary.