Investigator; Hybrid

Resp & Qualifications

PURPOSE: The role of the Special Investigations Unit (SIU) Investigator is to assist in the reduction and recuperation of losses to Care First through the detection, investigation, and resolution of low to medium level fraud, waste, and abuse schemes, resulting in the savings and recovery of funds.

• Independently conduct low to medium level investigations and provide support as part of an assigned team to all levels (low to medium) investigations of suspected fraud, waste, and abuse. In conjunction with assigned team or management, develop and execute investigative plans that may include performance of audits of financial business records, provider and subscriber medical data, claims, systems report, medical records, analysis of contract documents, provider/subscriber claims history, benefits, external data banks and other documents to determine the possible existence of fraud and/or abuse.
  
  Provide support for offsite audits/investigations and interviews when requested. Research provider/subscriber claims activity, operations manuals, data systems, medical policies, job duties and group benefit contracts to identify control deficiencies and non‑compliance. Investigator will develop documentation to substantiate findings including formal reports, spreadsheets, graphs, audit logs, use of anti‑fraud software and appropriately sourced reference materials. Must ensure audits and investigations are timely, effective and result in an overall achievement of unit goals.
• Investigate and analyze claims data using company anti‑fraud software, Excel, and other tools to proactively identify new potential cases. Investigator will develop documentation that supports conclusions, recommendations, and substantiates findings including formal correspondence, audit reports, spreadsheets, graphs, audit logs, anti‑fraud software analysis, and appropriately sourced reference materials. Investigator ensures timely maintenance and organization of case file documentation with a high level of detail and accuracy that clearly and concisely outlines investigative steps, case synopses, and findings and to preserve as potentially discoverable material.
• Initiate claim adjustments, voucher deducts, and voluntary refunds in order to recover funds. Record recoveries and savings following established processes.
• Perform special projects as assigned by management to meet the needs of the Special Investigations Unit.

Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.

Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

• Certified Fraud Examiner (CFE)
• Certified Insurance Fraud Investigator (CIFI)
• Certified Coder (CCS or CPC)-AHIMA or AAPC

2 years insurance, investigative, health care, nursing or law enforcement.

• Credential in a health care or investigations related area such as Certified Fraud Examiner (CFE), Accredited Health Fraud Investigator (AHFI), RN/LPN, or Certified Professional Coder (CPC).
• Knowledge of ICD 10 and CPT Codes, medical terminology, extensive training in claims and subscriber customer service methods, and previous experience in the health care industry.

• Knowledge of laws that pertain to public and insurance funds.
• Excellent communication skills both written and verbal.
• Ability to recognize, analyze, and solve a variety of problems.
• Ability to maintain effective interpersonal relationships.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

$53,928 - $107,107

The disclosed range…