Healthcare Fraud Investigator Clinical

Sanford Health•Sioux Falls, SD

52d•$29 - $47

About The Position

Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We’re proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint. Responsible for conducting audits and investigations of potentially fraudulent claim activity. Will plan, develop, and implement investigative processes and procedures.

Requirements

Bachelor’s degree in health related field or equivalent education is required.
Minimum 3 years’ experience in health insurance investigation/audit.

Nice To Haves

Master's Degree preferred
Accredited Health Care Fraud Investigator (AHFI) certification or Certified Fraud Examiner (CFE) preferred
Nursing or other clinical experience highly preferred

Responsibilities

Conduct preliminary investigations, involving internal and external research, detailed data analyses, review of medical records, and interviews of members, providers, and other third parties.
Analyzes information gathered by the investigation/audit and report findings, preparing written summaries and recommendations.
Conducts investigative interviews of patients and providers as necessary.
Prepare evidence package for referral to third parties including contract holders, state insurance fraud bureaus and law enforcement agencies.
Respond to subpoenas and requests for information from law enforcement agencies and State Departments of Insurance.
May represent company as a witness in judicial proceedings when appropriate.
Performs special projects requiring expertise in fraud detection, data analytics, investigation, claim auditing and other areas related to Special Investigations.
Completes reports of investigative findings and recommends investigative next steps.
Identifies root causes of fraud, proposing internal and external corrective actions to address these root causes.
Advises on investigative priorities, strategies, and techniques.
Apply laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during the investigation.
Share expertise and promoting investigative best practices among management and staff.
Educate and collaborate with various business units to raise awareness of potential concerns.
Must have excellent communication and interpersonal skills, along with strong analytical and problem-solving abilities.
Ability to work on complex projects with general direction and minimal guidance.