Investigator 1-2

Point32Health, Inc • Canton, MA

70d

About The Position

The Investigator I is an essential team member of the Special Investigation Init (SIU (Special Investigations Unit)) responsible for leading complex provider investigations related to fraud, waste, and abuse, and developing action plans to address the investigative findings and prevent future loss. The Investigator works closely with other members of the SIU to set investigative priorities, develop effective investigative strategies and techniques, and recommend measures to address new and evolving schemes.

Requirements

• Ability to produce clear, concise, and well-organized documents.
• Resilient, collaborative, flexible, innovative.
• Required (minimum): 1-3 years' related experience in health insurance fraud investigations.
• Required (minimum): Bachelor's degree
• Certified Professional Coder ("CPC")

Nice To Haves

• Certified Fraud Examiner ("CFE") designation a plus.
• Preferred: Related experience in audits/investigations.
• Preferred: Degree in a clinical or scientific field, business, accounting, computer science, or criminal justice

Responsibilities

• Lead straightforward and moderately complex investigations in specified areas of Fraud Waste and Abuse.
• Conduct internal and external research, review data analyses, review medical records, and interview members, providers, and other third parties.
• Apply laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during the investigation.
• Complete detailed reports of investigative activity and prepare summary findings notices for providers or other entities.
• As knowledge develops, expand investigative activities to include additional provider and service types.
• Work with SIU management to educate providers, recover overpayments, take action to prevent future loss, and monitor provider activity post-investigation.
• Identify root causes of fraud, waste and abuse and recommend internal and external corrective actions to address these root causes.
• Recommend investigative priorities, strategies, and techniques.
• Work with the analytics and intake team to develop and refine data mining to address new and evolving schemes and
• Share expertise and promote investigative best practices among SIU management and staff.
• Assist management in educating and collaborating with various business units to raise awareness of potential FWA (Fraud Waste and Abuse) concerns.
• Perform out-of-the-box thinking, collaborate with others, and make a difference every day.
• Other duties as assigned by the Manager or Director.

Benefits

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Religious, Grantmaking, Civic, Professional, and Similar Organizations
• Number of Employees: 1,001-5,000 employees