Special Investigator

Your career starts now. We are looking for the next generation of health care leaders.

** This position is remote however, you must live and be able to travel within Ohio as business needs.*
* At Ameri Health Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nations leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. Ameri Health Caritas is seeking talented, passionate individuals to join our team.

Together we can build healthier communities. If you want to make a difference, we would like to hear you.

Headquartered in Newtown Square, Ameri Health Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

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The Investigator is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full range of products at the Ameri Health Caritas Family of Companies (ACFC).;;;

** Major Accountabilities:*
* + 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.;;;

** Education/

Experience:

*
* + 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 Lead SIU Investigator position may be considered.;

+ Valid driver's license required

+ Data Analytics experience preferred.

+ 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 3-5 years experience conducting comprehensive health care fraud ;investigations; interacting with state, federal and local law enforcement agencies.

** Other

Skills:

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* + Health care industry and/or Medicare/Medicaid/Pharmacy/Behavioral Health/Pharmacy Benefit Management knowledge required.

+ 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…