Special Investigator

Amerihealth Caritas • ,

3d • Remote

About The Position

The Special Investigator conducts comprehensive investigations of reported, alleged, or suspected fraud involving the full range of products at the AmeriHealth Caritas Family of Companies (ACFC). The role supports Special Investigation Unit (SIU) responsibilities and works to ensure thoroughness, quality, timeliness, and cost control in fraud, waste, and abuse investigations. The position is remote within the United States and requires access to reliable high-speed internet of at least 50 Mbps download and 5 Mbps upload. Fully remote associates in states where service is required by contract, law, or regulation may submit for reimbursement of internet service.

The investigator researches and analyzes aberrant claims billing and practice patterns, conducts interviews, prepares investigative reports, represents ACFC in settlement negotiations, and maintains relationships with public officials and law enforcement. The position requires healthcare fraud investigation experience, knowledge of relevant healthcare programs and laws, strong analytical and communication skills, and a high degree of integrity when handling confidential information.

AmeriHealth Caritas is a mission-driven health care organization headquartered in Newtown Square, with more than 30 years of experience. It provides integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Requirements

• Bachelor's degree and at least two years of healthcare experience in fraud, waste, and abuse investigations and audits, or an associate's degree and at least four years of such experience.
• At least three years of experience conducting comprehensive health care fraud investigations and interacting with state, federal, and local law enforcement agencies.
• A valid driver's license.
• 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 when handling personal and confidential information.
• Analytical skills, ability to make deductions, and logical and sequential thinking.
• Knowledge of the health care industry and/or Medicare, Medicaid, pharmacy, behavioral health, or pharmacy benefit management.
• Solid knowledge of Medicaid, Medicare, and pharmacy benefit laws and requirements, as well as federal, state, civil, and criminal statutes.
• Experience with decision support tools used for data analysis.
• Advanced knowledge and experience with approaches to fraud, waste, and abuse.
• Working knowledge of Microsoft applications, especially Excel.
• Knowledge of internal and external resources available to assist in investigations.
• Reliable high-speed internet access for remote work, with at least 50 Mbps download and 5 Mbps upload.

Nice To Haves

• Experience with data analytics.
• Clinical experience.
• SIU and/or State Medicaid regulatory compliance work experience.
• Knowledge and proficiency in claims adjudication standards and procedures.
• Training, certifications, and experience commensurate with position requirements may be considered in lieu of formal educational requirements.

Responsibilities

• Ensure compliance with requirements related to Special Investigation Units and fraud, waste, and abuse investigations.
• Conduct investigations of potential fraud, waste, and/or abuse, with attention to thoroughness, detail, quality, timeliness, and cost control.
• Conduct comprehensive interviews with providers, members, and witnesses to obtain information admissible under generally accepted criminal and civil rules of evidence.
• Research and analyze aberrant claims billing and practice patterns using the Internet, data analysis tools, and other resources.
• Analyze data during investigations using available fraud detection software and corporate resources.
• Represent ACFC in settlement negotiations with providers, counsel, and other associated parties.
• Prepare and submit investigative reports covering all phases of investigations.
• Interpret and convey highly technical information to others.
• Establish and maintain liaison with public officials, law enforcement, and others to obtain assistance with investigations.
• Support SIU investigations and responsibilities, including intake, screening, reviews, referrals, recoveries, and provider investigative site visits.

Benefits

• Flexible work solutions, including remote options and hybrid work schedules.
• Competitive pay.
• Paid time off, including holidays and volunteer events.
• Health insurance coverage for the associate and dependents on Day 1.
• 401(k).
• Tuition reimbursement.
• Internet service reimbursement may be available to fully remote associates residing in states where service is required by contract, law, or regulation.

What This Job Offers

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