Special Investigator

Amerihealth Caritas•Mansfield, OH

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 position ensures compliance with requirements related to Special Investigation Units (SIUs) and fraud, waste, and abuse investigations. It performs investigative functions across intake, screening, reviews, referrals, recoveries, and provider investigative site visits. This role is remote within the United States, preferably for someone residing in Ohio. Remote associates must have reliable high-speed internet with at least 50 Mbps download and 5 Mbps upload. Fully remote associates residing in states where service is required by contract, law, or regulation may submit for reimbursement of internet service. AmeriHealth Caritas is a mission-driven health care organization headquartered in Newtown Square, with more than 30 years of experience. It provides 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 experience in healthcare fraud, waste, and abuse investigations and audits.
Experience and training or certifications commensurate with the position requirements may be considered in lieu of formal educational requirements.
Valid driver's license.
At least two years of experience conducting comprehensive health care fraud investigations and interacting with state, federal, and local law enforcement agencies.
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 ability to handle personal and confidential information confidentially.
Analytical skills, ability to make deductions, and a logical, sequential approach to 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.
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.

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.
Experience with decision support tools used for data analysis.

Responsibilities

Ensure compliance with requirements related to Special Investigation Units and fraud, waste, and abuse investigations.
Conduct thorough, timely, quality investigations of potential fraud, waste, and abuse, with attention to cost control.
Interview providers, members, and witnesses to obtain information suitable for use under generally accepted criminal and civil rules of evidence.
Research and analyze aberrant claims billing and practice patterns using the Internet and data analysis tools.
Analyze data 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 all aspects of SIU investigations and responsibilities, including intake, screening, reviews, referrals, recoveries, and provider investigative site visits.