Investigator, Science, Healthcare Compliance

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. Learn more about who we are at Point
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Health.

The Investigator I is an essential team member of the Special Investigation Init (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 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 straightforward and moderately complex investigations in specified areas of Fraud Waste and Abuse.
• Conduct internal and external research, review data analyses, review medical records, and interview 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.
• As knowledge develops, expand investigative activities to include additional provider and service types.
• 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 and Share expertise and promote investigative best practices among SIU management and staff.
• Assist management in 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 Manager or Director.

• Certification and Licensure Certified Professional Coder (“CPC”);
  Certified Fraud Examiner (“CFE”) designation a plus.
• Education Required (minimum):
  Bachelor’s degree
• Preferred:
  Degree in a clinical or scientific field, business, accounting, computer science, or criminal justice
• Experience Required (minimum): 1-3 years’ related experience in health insurance fraud investigations.
• Preferred:
  Related experience in audits/investigations.
• Skill Requirements Ability to produce clear, concise, and well-organized documents.
• Resilient, collaborative, flexible, innovative.

• Must be able to work under normal office conditions and work from home as…