Special Investigator (Remote NC)

Vaya Health

1d•Remote

About The Position

The Special Investigator works under the direct supervision of the Special Investigations Operations Manager and is responsible for the identification, investigation and prevention of healthcare fraud, waste, and abuse within the Vaya Health Network of contracted providers. The Special Investigator develops investigative summary reports and makes applicable referrals to the NC Division of Health Benefits, and recommendations as necessary to providers associated with investigation findings/outcomes.

Requirements

Knowledge of healthcare service definitions, service documentation, and service utilization requirements.
An intermediate level of knowledge of Local, State and Federal laws, rules, and regulations pertaining to insurance and/or healthcare services.
Possess comprehensive knowledge of fraud investigative procedures and judicial processes relating to fraud prosecutions.
Excellent decision-making abilities to determine the appropriate course of action during investigations and subsequent follow-up.
Ability to prepare detailed and comprehensive reports, to present facts clearly, and to instruct others in new methods and procedures; Excellent written communication skills for correspondence, case documentation, and report writing.
Extensive oral and written communication with providers, state and federal regulatory agencies, licensing entities, independent contractors, and members.
Present investigative findings with regulatory violations citations and ability to accurately describe scheme(s) to defraud Medicaid.
Intermediate or better proficiency with Microsoft Word, Outlook, and Excel and the ability to adapt to new and updated technologies and platforms.
Ability to work autonomously, exercising sound judgment and problem solving skills.
Ability to establish appropriate and respectful relationships/partnerships with persons with a wide range of ethnicities and abilities.
Bachelor’s degree required in Healthcare compliance, fraud analytics, and medical auditing; Health and Human Services government and/or public administration; Pre-law, Psychology, Social work, and/or a related human service field.
Must have 3 years of experience in a public agency, healthcare compliance and/or healthcare, fraud investigation.
Must live in North Carolina or within 40 miles of the NC border.
Ability to travel to Vaya’s Offices or within Vaya’s Catchment area as needed.

Nice To Haves

Three years post-degree experience of Medicaid Behavioral Health and/or Physical Health service delivery with demonstrated intermediate level knowledge in health care policies, procedures, and documentation standards.
Qualified Professional, Accredited Healthcare Fraud Investigator, Certified Fraud Examiner, or Certified Professional Coder preferred.

Responsibilities

Utilize established Vaya procedures to conduct inquiries and investigations into complaints, allegations, and referrals regarding suspected Fraud, Waste or Program Abuse.
Review healthcare claims to determine if provider payments were rendered in accordance with rules, regulations, service definition, service utilization, and contractual requirements.
Determine correct coding, billing, documentation, delivery of services and potential violations of federal and/or state regulation or Medicaid guidelines.
Perform reviews (desk, virtual, and/or on-site) interview providers, members, and stakeholders, and review medical records to verify compliance with program policies, standards of health care, appropriateness of services and/or medical necessity.
Prepare reports and exhibits from the findings of provider investigations and develop recommendations or intervention strategies to correct or prevent abusive practices, including proposals to recover inappropriately paid moneys or to suspend or terminate program participation.
Refer suspected fraud cases to the DHB Office of Compliance and Program Integrity.
Participate in both informal and formal appeal processes, defending SIU decisions before a Vaya appeal panel, hearing officers, and/or administrative law judges.
Provide litigation testimony as applicable.
Work in conjunction with various regulatory bodies.
Propose new fraud prevention edits for automated claims/billing system when new fraudulent schemes are identified.
Other duties may include providing technical assistance and provider education when assigned based upon need, area of expertise, special interests and availability of resources.