Special Investigator

Amerihealth Caritas•Manchester, NH

1d•Remote

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 ensuring compliance with all requirements related to Special Investigation Units and fraud, waste and abuse investigations. The Investigator will conduct thorough investigations, including interviews with providers, members, and witnesses, and perform research using the Internet and data analysis tools to identify aberrant billing and practice patterns. The role also involves analyzing data using fraud detection software, representing the company in settlement negotiations, preparing detailed investigative reports, and liaising with public officials and law enforcement. Key functions include intake, screening, reviews, referrals, recoveries, and provider investigative site visits.

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.
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.
Health care industry and/or Medicare/Medicaid/Pharmacy/Behavioral Health/Pharmacy Benefit Management knowledge preferred.
Clinical Experience preferred.
SIU and/or State Medicaid regulatory compliance work experience preferred.
Knowledge and proficiency in claims adjudication standards & procedures preferred.
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.

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.