Investigator, Special Investigative Unit; Remote- reside

JOB DESCRIPTION Job Summary

Provides investigative support for special investigation unit (SIU) activities. Responsible for supporting for the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse (FWA). Responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care, and recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence.

• Responsible for developing leads presented to the special investigation unit (SIU) to assess and determine whether potential fraud, waste, or abuse (FWA) is corroborated by evidence.
• Conducts both preliminary assessments of FWA allegations, and end-to-end investigations, including but not limited to witness interviews, background checks, data analytics to identify outlier billing behavior, contract and program regulation research, provider and member education, findings identification and communications development, recommendations and preparation of over payment identifications, and closure of investigative cases.
• Completes investigations within the mandated period of time required by either state and/or federal contracts and/or regulations.
• Conducts both on-site and desktop investigations.
• Conducts low to medium, and extensive investigations, including reviews of medical records and data analysis, and makes determinations as to whether the investigation and/or audit identified potential FWA.
• Performs accurate and reliable medical review audits that may also include coding and billing reviews.
• Produces audit reports for internal and external review.
• Coordinates with various internal customers (e.g., provider services, contracting and credentialing, healthcare services, member services, claims, etc.), to gather documentation pertinent to investigations.
• Detects potential health care FWA through the identification of aberrant coding and/or billing patterns through utilization review.
• Prepares appropriate FWA referrals to regulatory agencies and law enforcement.
• Documents appropriately all case related information in the case management system in an accurate manner, including storage of case documentation following SIU related requirements.
• Prepares detailed preliminary and extensive investigation referrals to state and/or federal regulatory and/or law enforcement agencies when FWA is identified as required by regulatory and/or contract requirements.
• Renders provider education on appropriate practices (e.g., coding) as appropriate based on national or local guidelines, contractual, and/or regulatory requirements.
• Interacts with regulatory and/or law enforcement agencies regarding case investigations.
• Prepares audit results letters to providers when over payments are identified.
• Ensures compliance with applicable contractual requirements, and federal and state regulations.
• Complies with SIU policies as and procedures as well as goals set by SIU leadership.
• Supports SIU in arbitrations, legal procedures, and settlements.
• Actively participates in Medicaid Fraud Control Unit (MFCU) meetings and round tables on FWA case development and referrals.
• May work with other internal departments, including compliance, corporate legal counsel, and medical affairs to achieve and maintain appropriate anti-fraud oversight.

• At least 2 years of investigative experience in the health care industry, or equivalent combination of relevant education and experience.
• Valid and unrestricted driver’s license.
• Proven investigatory skills including ability to organize, analyze, and effectively determine risk with corresponding solutions, and remain objective and separate facts from opinions.
• Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.
• Knowledge of managed care and Medicaid, Medicare, and Marketplace programs.
• Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.
• Understanding of data mining and use of data analytics to detect FWA.
• Ability to research and interpret regulatory requirements.
• Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels.
• Strong presentation skills with ability to create and deliver training, informational and other types of programs.
• Strong logical, analytical, critical-thinking and problem-solving skills.
• Strong…