Investigator I

Point32Health • Providence, RI

2d • $66,524 - $99,786

About The Position

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

The role leads straightforward and moderately complex investigations, researches and reviews data and medical records, interviews members, providers, and other third parties, and applies relevant laws, regulations, plan policies, contract provisions, coding and coverage rules, and industry standards. The Investigator documents investigative activity, prepares findings notices, and works with SIU management and other teams on provider education, overpayment recovery, corrective actions, and post-investigation monitoring. The role also identifies root causes, recommends investigative priorities and strategies, supports data-mining improvements, and shares investigative expertise and best practices.

Requirements

• Bachelor’s degree.
• One to three years of related experience in health insurance fraud investigations.
• Certified Professional Coder (CPC) certification.
• Ability to produce clear, concise, and well-organized documents.
• Resilient, collaborative, flexible, and innovative.
• Ability to work under normal office conditions and from home as required.
• May be required to attend meetings at other company locations or external meetings and perform on-site evaluations of provider practice locations.
• Ability to use a telephone/headset and PC/keyboard simultaneously and sit for extended durations.
• May be required to work additional hours beyond the standard work schedule.

Nice To Haves

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

Responsibilities

• Lead straightforward and moderately complex investigations in specified areas of fraud, waste, and abuse.
• Conduct internal and external research, review data analyses and 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 investigations.
• Complete detailed reports of investigative activity and prepare summary findings notices for providers or other entities.
• Expand investigative activities to additional provider and service types as knowledge develops.
• Work with SIU management to educate providers, recover overpayments, prevent future loss, and monitor provider activity after investigations.
• Identify root causes of fraud, waste, and abuse and recommend internal and external corrective actions.
• Recommend investigative priorities, strategies, and techniques.
• Work with the analytics and intake team to develop and refine data mining addressing new and evolving schemes.
• Share expertise and promote investigative best practices among SIU management and staff.
• Assist management in educating and collaborating with business units to raise awareness of potential fraud, waste, and abuse concerns.
• Perform 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.
• Benefits supporting career development, individual and family health, and financial health.
• Eligibility for variable pay.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level