Senior Investigator

Point32Health•Canton, MA

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 and developing action plans to address investigative findings and prevent future loss. The role collaborates with SIU colleagues to set priorities, develop investigative strategies and techniques, and recommend responses to new and evolving schemes. It also serves as a resource to SIU members and other departments in areas of investigative and clinical expertise. The position involves researching and analyzing information, reviewing medical records, interviewing members, providers, and other third parties, and applying relevant laws, regulations, policies, contract terms, coding and coverage rules, and industry standards. The Senior Investigator prepares and reports findings, works with SIU management on provider education and overpayment recovery, and recommends corrective actions and monitoring to prevent future loss. The role also collaborates with analytics, intake, and other business units to refine data mining and build awareness of potential fraud, waste, and abuse concerns. The role 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. The work is performed under normal office conditions and may be done from home as required. Attendance at meetings at other company locations or external meetings may be required, as may additional hours beyond the standard work schedule.

Requirements

Bachelor's degree, preferably in a clinical or scientific field, business, computer science, or criminal justice.
Certified Professional Coder (CPC) certification.
5–7 years of related experience in health insurance fraud investigations.
Ability to produce clear, concise, and well-organized documents.
Resilient, collaborative, flexible, and innovative.
Able 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 involve 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 analyses, medical-record reviews, and interviews with members, providers, and other third parties.
Apply laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during investigations.
Prepare investigative findings reports and report findings to providers.
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.
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 coverage
Dental coverage
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