Investigator, Special Investigations Unit | Remote

HealthFirst

1d•Remote

About The Position

The Investigator within the Special Investigations Unit (SIU) will be responsible for effectively carrying out complex investigations of alleged misconduct and Fraud, Waste and Abuse by providers, representatives, employees, members, and others. This position is 100% remote.

Requirements

Must have an Associate's degree from an accredited institution in criminal justice or related field, or five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies, or seven years of professional investigative experience involving economic or insurance related matters
Knowledgeable of applicable fraud statutes, CMS guidelines, federal and state requirements
Must demonstrate a high degree of integrity & appropriate treatment of confidential information
Must exhibit professional conduct in dealing with internal & external individuals and work with a level of sensitivity to target populations
Ability to adhere to policies, rules and regulations
Must have working knowledge of Microsoft Word, Excel, and Outlook

Nice To Haves

Bachelor's degree from an accredited institution
Strong critical thinking and analytical skills
Knowledge of medical claims processing and investigations
Knowledge of Medicare & Medicaid products

Responsibilities

Conduct investigations of Providers, Representatives, Employees, Members, contracted groups and others
Compile data into written reports: collect, utilize & interpret data obtained from a variety of reports and other sources, thereby identifying & documenting questionable patterns related to operation, and other practices which merit further investigation
Investigations may be of a more complex nature i.e., multiple allegations; Medicaid and Medicare investigations or investigations involving extensive research, income verifications, and other criteria for eligibility
Research investigations; prepare, review and edit investigation reports for submission to AVP, SIU and Marketing Incidents Committee
Present relevant investigative findings: prepare and deliver presentation summaries to the Marketing Incidents Committee, and/or other groups as needed
Log investigations, ensure accuracy, and completion of entries
Inform the Special Investigations Unit leaders of potential or actual problem areas; identify & suggest corrective action or improvement
Assist Special Investigations Unit leaders with Fraud, Waste and Abuse issues, and perform other duties as necessary or assigned
Maintain assigned investigation files, document evidence, and prepare comprehensive investigation reports
Establish good working relationships with Healthfirst employees & external contacts of the Special Investigations Unit Department, including Federal, State and Local law enforcement agencies