Special Investigation Unit Investigator (44911)

Community Care Plan - Sunrise, FL

Hybrid - Sunrise, FL

Ambulatory Health Care Services

About the position

The Special Investigations Unit Investigator is responsible for the investigation of potential fraud, waste, and abuse cases involving health plan providers and members. The Special Investigations Unit Investigator responsibilities include but are not limited to case management, research, investigation, documentation, and overpayment recovery.

Responsibilities

• Accountable for managing a caseload of referrals and investigations involving potential member and/or provider fraud, waste, and abuse.
• Documents all appropriate case activity in case tracking system.
• Ensures compliance with all state and federal requirements related to FWA and FWA investigations.
• Performs data-mining activities to identify potential cases for investigation.
• Analyzes data as part of the investigative process.
• Performs research to analyze aberrant claims billing and practice patterns.
• Investigates and documents all fraud, waste, and abuse referrals and cases with a focus on thoroughness and attention to detail, quality, timeliness, and cost control.
• Testifies on investigations documented, as needed.
• Conducts comprehensive interviews with providers, members, and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.
• Conducts investigative steps out in the field throughout the service area as needed.
• Prepares and submits investigative reports covering all phases of the investigation.

Requirements

• Bachelor level education
• Minimum 3-5 years experience conducting comprehensive health care FWA investigations.
• Ability to work independently with minimal supervision and manage a high volume of assignments.
• High degree of integrity and confidentiality required handling information that is considered personal and confidential.
• Analytical skills and ability to make deductions, logical and sequential thinker.
• Strong verbal and written communication skills.
• Health care industry and/or Florida Medicaid knowledge required.
• Advanced knowledge and experience working on various approaches to health care fraud, waste, and abuse.
• Working knowledge of Microsoft applications, especially Excel, required.
• Knowledge of available resources (internal and external) to assist in investigations.

Nice-to-haves

• Medical terminology knowledge and/or experience with CPT and ICD-10 coding preferred.
• Knowledge of suspected FWA trends, potential schemes, and matters of interest to law enforcement and regulators.
• Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE) preferred.