Investigative Auditor

Neighborhood Health Plan of Rhode Island•Smithfield, RI

4d•Onsite

About The Position

The Investigative Auditor handles the intake, triage, review, and documentation of Fraud, Waste, and Abuse (FWA) allegations referred to the Special Investigations Unit (SIU), and conducts related audits. After independently reviewing allegations, the auditor determines whether to recommend closing referrals that lack sufficient supporting evidence or advancing matters to an audit based on initial findings. The role may also monitor and analyze utilization patterns and potentially fraudulent activity through prepayment claims reviews, post-payment auditing, and provider record reviews. It ensures claims, medical records, and reimbursement documentation comply with federal and state regulations, contractual requirements, and industry standards. The auditor assists with recovery of funds lost to FWA, reports suspected fraud to the Office of Program Integrity, manages regulatory notices and case summaries, and coordinates with external entities such as government agencies and law enforcement. The position works independently and collaboratively with the SIU and other business areas to oversee the organization’s FWA program, identify organizational non-compliance, and prepare internal and external FWA reporting.

Requirements

Associate’s degree in Health Information Management, Health Care Administration, Accounting/Finance, or a related field, plus at least two years of experience conducting healthcare FWA investigations and/or audits, or other healthcare-related audits within a Managed Care Organization; alternatively, at least three years of experience conducting healthcare FWA investigations and/or audits within a Managed Care Organization in lieu of a degree.
Proven investigatory skills, including the ability to organize, analyze, assess risk, identify corresponding solutions, remain objective, and distinguish facts from opinions.
Knowledge of Managed Care and Medicaid/Medicare program guidelines, medical terminology, anatomy, and healthcare delivery systems.
Fundamental understanding of claim billing codes, CPT/HCPCS/ICD coding concepts, and healthcare billing concepts and data processing.
Ability to research and interpret regulatory requirements.
Effective interpersonal skills and ability to interact with individuals at all levels.
Excellent oral and written communication and presentation skills, including the ability to create and deliver training, informational, and other programs.
Strong analytical, critical-thinking, investigative, and problem-solving skills.
Ability to multitask and work effectively across geographic and functional boundaries.
Detail-oriented, self-motivated, and able to meet tight deadlines.
Ability to develop realistic and motivating goals and objectives, track progress, and adapt to changing priorities.
Energetic and forward-thinking, with high ethical standards and a professional image.
Collaborative and team-oriented.
Advanced skills in Microsoft Office (Word, Excel, PowerPoint, and Outlook), SharePoint, and the Intra/Internet, and proficiency incorporating and merging documents from various applications.

Nice To Haves

Bachelor’s degree.
Experience in medical-records review, claims processing, and/or utilization or case management in clinical practice.
National Health Care Anti-Fraud Association certification (AHFI), Certified Fraud Examiner (CFE), or America’s Health Insurance Plans Health Care Anti-Fraud Associate (HCAFA) designation.
American Academy of Professional Coders (AAPC) or similar certification.

Responsibilities

Respond to allegations of potential Fraud, Waste, and Abuse, including intake, case triage, and investigation of allegations involving members and providers.
Analyze enrollment data, contract terms, financial records, provider and subscriber claims history, and other documentation to determine FWA and identify potential patterns.
Apply regulatory and contractual requirements, as well as internal policies and procedures, during case investigations.
Conduct data analysis, research, and claims-data reviews to identify trends, patterns, outliers, and emerging healthcare FWA issues using fraud technology.
Perform prepayment claims reviews and post-payment audits, as applicable.
Research and investigate member identity theft cases referred by Member Services and investigate potentially compromised member information related to security breaches.
Communicate routinely with members and providers about investigative issues, findings, recoveries, and educational feedback where appropriate.
Maintain the integrity of FWA case documentation and update tracking systems with accurate records of calls, evidence, referrals, inquiries, and case events, including documentation for court-related discovery.
Establish and maintain relationships with external agencies, including the Department of Health, Office of Inspector General, Federal Drug Enforcement, OPI, EOHHS, Rhode Island Attorney General, U.S. Attorney, and state and local law enforcement.
Prepare data requests from external law enforcement agencies as required.
Develop concise reports, present findings to providers, and participate in negotiated resolution of issues at management’s direction.
Track and report claim adjustments, settlement agreements, and payment-plan agreements resulting from investigations or court-ordered restitution.
Use findings to identify potential policy changes and determine appropriate actions based on line of business, issue severity, regulatory requirements, and plan exposure.
Draft corrective action plans as appropriate.
Assist with recovery of funds lost due to FWA and report suspected fraud to the Office of Program Integrity.
Manage regulatory notices, including HPMS memos, and case summaries; coordinate with external entities.
Assist in preparing internal and external FWA reporting.
Perform other duties as assigned.