Investigator II

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.

The Investigator II is an essential team member of the Special Investigation Unit (SIU) 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 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.

• Lead moderately complex to complex investigations in established and emerging areas of Fraud Waste and Abuse (FWA) 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.
• Complete detailed reports of investigative activity and prepare summary findings notices for providers or other entities.
• 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 recommending internal and external corrective actions to address these root causes.

Develop new investigations based upon case findings. 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. Share expertise and promote investigative best practices among SIU management and staff. Educate and collaborate with various business units to raise awareness of potential FWA concerns. Perform out-of-the-box thinking, collaborate with others, and make a difference every day!

Other duties and projects as assigned.

• Certification and Licensure Certified Professional Coder (“CPC”);
  Certified Fraud Examiner (“CFE”) designation a plus.
• Education Required (minimum):
  Bachelor’s degree.
• Preferred:
  Degree preferably in a clinical or scientific field, business, accounting, computer science, or criminal justice.
• Experience Required (minimum): 3-5 years’ related experience in health insurance and/or fraud investigations.
• Preferred:
  Experience in audits/investigations including experience drafting and distributing summary findings notices to providers or other entities.
• 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 under normal office conditions and work from home as required. May be required to attend…