Jr Investigator, Program Integrity

Evolent

2d•Remote

About The Position

Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture. What You’ll Be Doing: Put your passion where it meets purpose! Evolent attracts some of the brightest minds in health care. Surround yourself with talented, driven colleagues who share a passion for better health outcomes and a more connected care journey. We are hiring a Junior Investigator to join our Program Integrity Unit. Evolent’s Program Integrity Unit works closely with our health plan clients to identify, reduce and eliminate health care fraud, waste and abuse.

Requirements

Strong analytical and critical thinking skills.
Ability to identify trends, anomalies, and potential indicators of Fraud, Waste, and Abuse.
Strong attention to detail and organizational skills.
Ability to research information from multiple sources (governmental, regulatory, health plan).
Proficiency with Microsoft Office applications, particularly Excel, Word, and Outlook.
Ability to learn and utilize investigative, claims, and case management systems.
Effective written and verbal communication skills.
Ability to maintain strict confidentiality and handle sensitive information appropriately.
Ability to manage multiple assignments and meet established deadlines.
One (1) to three (3) years of experience in healthcare operations, claims analysis, fraud detection, compliance, auditing, investigations, data analysis, or a related field preferred.
Experience working with healthcare claims, provider data, or medical records.
Basic understanding of healthcare fraud, waste, and abuse concepts.
Bachelor's degree in criminal justice, Healthcare Administration, Business Administration, Finance, Health Information Management, or a related field; or equivalent combination of education and experience.
Experience with healthcare claims processing, SIU operations, compliance, auditing, or investigative support.
Experience using claims databases, data analytics tools, or case management systems.
High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router.

Nice To Haves

Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI)

Responsibilities

Perform preliminary research utilizing internal and external databases to identify potential indicators of Fraud, Waste, and Abuse.
Assist investigators in the development and progression of investigations.
Gather, compile, and organize investigative information from multiple data sources.
Identify potential investigative leads and trends from Health Care Fraud Prevention Partnership (HFPP) memoranda, referrals, and other sources.
Conduct preliminary reviews of provider, member, and claims information to support case development.
Gather and review data in response to inquiries received by the Special Investigations Unit.
Utilize claims and analytical databases to retrieve and review claims data.
Review claims, utilization, and payment data for aberrancies, patterns, trends, and anomalies that may warrant further investigation.
Assist in analyzing data to support investigative findings and recommendations.
Prepare summaries of research findings and investigative observations for review by SIU investigators and leadership.
Document investigative activities, findings, and case updates within the SIU case management system.
Maintain accurate, complete, and timely records for assigned cases and referrals on the internal site.
Prepare correspondence and supporting documentation in accordance with departmental procedures.
Maintain up-to-date notes and documentation on assigned projects.
Utilize approved electronic vendor platforms to distribute outbound correspondence to providers.
Assist with tracking provider responses and maintaining communication records.
Monitor and track workflow activities to ensure timely completion of assigned tasks.
Participate in SIU meetings and contribute to operational discussions and investigative planning.
Maintain confidentiality of sensitive investigative, member, provider, and organizational information.
Stay current on Fraud, Waste, and Abuse trends, regulations, and investigative best practices.
Perform other duties, projects, and assignments as requested.