Senior Investigator

Point32Health • Canton, MA

4d • $92,414 - $138,621

About The Position

The Senior Investigator is an essential member of the Special Investigations Unit (SIU), leading complex provider investigations related to fraud, waste, and abuse. The role develops action plans to address investigative findings and prevent future losses, works with SIU colleagues to set priorities and strategies, and recommends measures to address new and evolving schemes. The Senior Investigator also provides expertise and guidance to SIU colleagues and other departments in areas of investigative and clinical expertise.

The role involves researching and analyzing information, reviewing medical records, interviewing members, providers, and other third parties, applying relevant laws and plan rules, and documenting and communicating findings. It also works with management and other teams to educate providers, recover overpayments, prevent future losses, monitor provider activity, improve data mining, and address root causes of fraud, waste, and abuse.

The position requires a bachelor's degree, preferably in a clinical or scientific field, business, computer science, or criminal justice; CPC certification; and 5–7 years of related experience in health insurance fraud investigations. A CFE designation and three years of related audit or investigation experience are preferred. Work is performed under normal office conditions and from home as required. Meetings may take place at other company locations or externally, and the work may involve extended sitting and simultaneous use of a telephone/headset and computer. Additional hours beyond the standard work schedule may be required.

Requirements

• Certified Professional Coder (CPC) certification.
• Bachelor’s degree; preferably in a clinical or scientific field, business, computer science, or criminal justice.
• 5–7 years of related experience in health insurance fraud investigations.
• Ability to produce clear, concise, 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.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond the standard work schedule.

Nice To Haves

• Certified Fraud Examiner (CFE) designation.
• Three years of related experience in audits or investigations.

Responsibilities

• Lead complex investigations involving internal and external research, detailed data analysis, medical-record review, and interviews with members, providers, and other third parties.
• Apply laws, regulations, plan policies and guidelines, contract provisions, coding and coverage rules, and industry standards to investigative information.
• Prepare reports of investigative findings and report findings to providers.
• Work with SIU management to educate providers, recover overpayments, prevent future losses, 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 to address new and evolving schemes.
• Share expertise and promote investigative best practices among SIU management and staff.
• Educate and collaborate with business units to raise awareness of potential fraud, waste, and abuse concerns.
• Perform other duties as assigned by the 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; bonus, commission, benefits, and other compensation are at the company’s discretion.

What This Job Offers

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