Senior Fraud Investigator
About The Position
At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. Job Summary BASIC FUNCTION HCSC is looking for a dynamic individual to join its Fraud Investigations team! This position is responsible for planning and developing investigation tools and techniques to conduct detailed investigations of potentially fraudulent claim activity by members, employees and providers, both internally and externally, as well as make recommendations for prosecution, recovery and litigation. Also, reviews operational controls, and claim system controls and protocols, and recommends enhancements to reduce the potential for fraud. Incumbent performs detailed analysis of claim payment data, prepares analysis and evidentiary reports; monitors potentially fraudulent claims and suspect billing patterns along with inquiries and other business matters for HCSC and all its subsidiaries and subcontractors; and be responsible for criminal and civil case development along with the organization and preparation of cases being forwarded for prosecution or litigation. NOTE: this role is hybrid/flex and requires in-office visibility three days per week, working from home the other two days. Relocation is NOT offered; sponsorship will NOT be extended either now or in the future.
Requirements
- Bachelor’s Degree.
- Three (3) years healthcare fraud investigative experience OR 5 years law enforcement experience (local, state, or federal).
- Familiarity with laws applicable to health care fraud.
- Ability to develop effective liaison relations which facilitate case identification, investigation, and prosecution.
- Ability to independently prepare reports of interview and other documentation accurately reflecting investigative activity and results.
- Clear and concise verbal and written communication skills.
- Proficient utilization of MS suite of products (Word, Excel, PowerPoint) as well as Workday.
Nice To Haves
- Certified Professional Coder
- Certified Fraud Examiner
- Accredited Health Care Fraud Investigator
- Knowledge of health care claims processing and benefits administration
Responsibilities
- planning and developing investigation tools and techniques to conduct detailed investigations of potentially fraudulent claim activity by members, employees and providers, both internally and externally
- make recommendations for prosecution, recovery and litigation
- reviews operational controls, and claim system controls and protocols, and recommends enhancements to reduce the potential for fraud
- performs detailed analysis of claim payment data
- prepares analysis and evidentiary reports
- monitors potentially fraudulent claims and suspect billing patterns along with inquiries and other business matters for HCSC and all its subsidiaries and subcontractors
- responsible for criminal and civil case development along with the organization and preparation of cases being forwarded for prosecution or litigation
Benefits
- health and wellness benefits
- 401(k) savings plan
- pension plan
- paid time off
- paid parental leave
- disability insurance
- supplemental life insurance
- employee assistance program
- paid holidays
- tuition reimbursement
- annual incentive bonus plan
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
