Special Investigator

Amerihealth Caritas•Washington, DC

5d•$80,400 - $109,500•Hybrid

About The Position

The Investigator is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full range of products at the AmeriHealth Caritas Family of Companies (ACFC). This role requires a hybrid work arrangement, with the expectation of residing in DC or surrounding areas (Montgomery, Prince George's, MD, or Arlington or Fairfax, Virginia, counties or cities of Alexandria and Falls Church, VA). Site visits are required as needed. For remote or hybrid roles, a reliable high-speed internet connection (minimum 50 Mbps download and 5 Mbps upload) is necessary. AmeriHealth Caritas is a mission-driven organization with over 30 years of experience, delivering comprehensive, outcomes-driven care and offering integrated managed care products, pharmaceutical benefit management, specialty pharmacy services, behavioral health services, and other administrative services.

Requirements

Bachelor's degree with a minimum of two years of experience in the healthcare field working in fraud, waste, and abuse investigations and audits OR An associate's degree, with a minimum of four years of experience working in healthcare fraud, waste, and abuse investigations and audits.
Experience and training/certifications commensurate with position requirements in lieu of formal educational requirements for the SIU Investigator position may be considered.
Valid driver’s license required
Ability to work independently with minimal supervision, and manage a high volume of assignments.
Strong verbal and written communication skills.
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.
A minimum of 3 years of experience conducting comprehensive health care fraud investigations; interacting with state, federal, and local law enforcement agencies.
Health care industry and/or Medicare/Medicaid/Pharmacy/Behavioral Health/Pharmacy Benefit Management knowledge required.
Solid knowledge of Medicaid, Medicare, and pharmacy benefit laws and requirements; federal, state, civil and criminal statutes.
Experience with decision support tools used for data analysis.
Advanced knowledge and experience working on various approaches to 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

Experience with Data Analytics preferred.
Clinical Experience preferred.
SIU and/or State Medicaid regulatory compliance work experience preferred.
Knowledge and proficiency in claims adjudication standards & procedures preferred.

Responsibilities

Ensures compliance with all requirements related to Special Investigation Units and fraud, waste and abuse investigations.
Conducts investigations of potential fraud, waste and/or abuse with a focus on thoroughness and attention to detail, quality, timeliness and cost control.
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.
Proactively performs research using the Internet, data analysis tools, etc., to analyze aberrant claims billing and practice patterns.
Analyzes data as part of the investigative process using available fraud detection software and corporate resources.
Represents ACFC in conducting settlement negotiations with providers, counsel and/or other associated parties.
Prepares and submits investigative reports covering all phases of the investigation.
Interprets and conveys highly technical information to others.
Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations.
Performs necessary functions to support all aspects of SIU investigations and responsibilities to include, but not limited to: Intake; Screening; Reviews; Referrals; Recoveries; and Provider Investigative Site Visits.