External Title Fraud Investigator Associate

Safe Guard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse.

We are looking to add a Fraud Investigator Associate to our SGS team of talented professionals.

What you'll do:

The position is an entry level fraud investigator/auditor position expected to work under the direct supervision of a team manager and/or team lead. The team performs high level complex investigations of medical professional service providers and develops cases/reports for future action, including referral to law enforcement, education, over payment recovery and other administrative actions. This position will support the team of fraud investigators/auditors and will work with internal resources and external agencies to develop cases/audits and corrective actions as well as respond to requests for data and support.

• The investigator uses good judgment and will work under the direct supervision of team manager and/or team lead
• The investigator/audit associate will work in support of a team who works with state and/or federal investigators and other personnel.
• The investigator handles multiple caseload assignments concurrently; organizes and analyzes information in support of the team’s workload
• The Investigator may also be required to assist in the completion of complex reports that apply regulations or rules to the program(s) affected by the behavior being reviewed.
• Investigator will work collaboratively within the team and participate in researching and understanding the relevant offenses being reviewed; participate in conducting efficient and effective investigations/audits concerning those alleged offenses and detect or verify suspected violations; obtain information and evidence by observation, record examination, and interview.
• Investigator/auditor will collaborate with team members to analyze the results of the investigation/audit to ascertain if the allegations have been corroborated and work with others to determine the appropriate steps that need to be taken to address the issues.
• As part of an investigation, the investigator will need to prepare correspondence; be objective and accurate and communicate with others with tact.
• There may be times when investigators need to react to unplanned situations, be flexible in planning their activities and adopt effective courses of action.
• As investigators will be working with health privacy information, they also must maintain confidentiality and understand all the laws, rules and regulations concerning health privacy.
• Telework available from NE UPIC jurisdiction (Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New York, Pennsylvania, New Jersey, Delaware, Maryland, and the District of Columbia (Washington, DC).

Basic Qualifications:

• 0 years’ experience with BS/BA, 4 years’ experience with a HS diploma/equivalent
• Investigative and analytical experience
• Strong communication and organization skills
• Strong PC knowledge and skills
• US. citizenship required

The most competitive candidates will have:

• Strong background in investigations or compliance audits.
• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases and identifying over payments.
• Knowledge of investigative or audit practices regarding healthcare providers.
• Knowledge of Medicare and/or Medicaid programs and the rules, regulations, policies and procedures
• Background in evaluating, reviewing and analyzing medical claims and records
• Ability to learn and operate a variety of data systems, equipment and tools used in investigations

Essential Functions:

• Ability to perform research and draw…