Senior Investigator

Who We Are Point
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Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point
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Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are.

We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point
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Health .

Job Summary The Senior Investigator is an essential team member of the SIU (Special Investigations Unit), responsible for leading complex provider investigations related to fraud, waste, and abuse, and developing action plans to address the investigative findings and prevent future loss. The Senior Investigator works closely with other members of the SIU to set investigative priorities, develop effective investigative strategies and techniques, and recommend measures to address new and evolving schemes.

The Senior Investigator also serves as a resource to fellow SIU members and other Plan departments in the investigator’s areas of investigative and clinical expertise.

Job Description

Key Responsibilities /Duties – what you will be doing (top five):

Lead complex investigations, involving internal and external research, detailed data analyses, review of medical records, and interviews of members, providers, and other third parties.

Apply laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during the investigation.

Prepare reports of investigative findings and reporting investigative findings to providers.

Work with SIU management to educate providers, recover over payments, take action to prevent future loss, and monitor provider activity post-investigation

Identify root causes of fraud, waste and abuse and recommend internal and external corrective actions to address these root causes.

Recommend investigative priorities, strategies, and techniques.

Work with the analytics and intake team to develop and refine data mining to address new and evolving schemes.

Sharie expertise and promoting investigative best practices among SIU management and staff. Educating and collaborating with various business units to raise awareness of potential FWA (Fraud Waste and Abuse) concerns.

Perform out-of-the-box thinking, collaborate with others, and make a difference every day!

Other duties as assigned by the Director.

Qualifications – what you need to perform the job Certification and Licensure:

Certified Professional Coder (“CPC”)Certified Fraud Examiner (“CFE”) designation a plus.

Education Required (minimum):
Bachelor’s degree, preferably in a clinical or scientific field, business, computer science, or criminal justice.

Preferred:

Experience Required (minimum): 5-7 years’ related experience in health insurance fraud investigations.

Preferred: 3 years’ related experience in audits/investigations.

Skill Requirements Ability to produce clear, concise, and well-organized documents.

Resilient, collaborative, flexible, innovative.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

Must be able to work…