Investigator I

Point32Health • Providence, RI

1d

About The Position

The Investigator I is an essential member of Point32Health’s Special Investigations Unit (SIU), leading straightforward and moderately complex provider investigations involving fraud, waste, and abuse. The role develops action plans based on investigative findings to address concerns and prevent future losses. The Investigator works with other SIU members to set investigative priorities, develop strategies and techniques, and recommend responses to new and evolving schemes.

The position includes researching and analyzing information, reviewing medical records, interviewing relevant parties, applying applicable laws and policies, and documenting findings. The Investigator also works with SIU management and partner teams on provider education, overpayment recovery, corrective actions, ongoing monitoring, and data-mining improvements. Work is performed under normal office conditions and from home as required, with possible meetings at other locations and on-site provider evaluations.

Requirements

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

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 and 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.
• Collaborate with the analytics and intake team to develop and refine data mining for new and evolving schemes.
• Share expertise and promote investigative best practices among SIU management and staff.
• Help management educate and collaborate 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