Auditor/Investigator II

About Our Client

The organization is a not-for-profit corporation collaborating with public and private sectors to ensure high quality, safe, and efficient delivery of health care and human services programs. It operates multiple business lines including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. The organization is also recognized nationally for its efforts in combating fraud, waste, and abuse for large entities across the country. Additionally, it offers grant opportunities through its Foundation to support programs serving underserved communities.

About the Opportunity

The Auditor/Investigator II role is responsible for ensuring the accuracy and integrity of claims processes by conducting thorough audits and investigations. This position plays a critical role in identifying potential fraud, waste, or discrepancies in claims submissions, contributing to the organization's mission to maintain program compliance and financial integrity. The role involves data analysis, stakeholder communication, and providing recommendations to management to resolve claims effectively.

Responsibilities

• Conduct routine and impartial audits and investigations of customer claims from initiation to closure.
• Address customer inquiries and concerns related to audits and investigations, escalating issues as necessary.
• Compile detailed and organized records of findings, ensuring legal and regulatory compliance.
• Develop and implement strategies to identify and prevent fraudulent activities in claims processing.
• Conduct interviews with witnesses, claimants, and stakeholders to gather relevant information.
• Communicate with internal teams to ensure proper processing of audits and investigations.
• Clearly and professionally communicate findings to customers, claimants, and stakeholders.
• Support training and development of other auditors and investigators.
• Manage work priorities in coordination with management.

Requirements

• Minimum Bachelor's Degree or equivalent experience.
• 2 to 4 years of relevant experience required; 5 to 7 years preferred.
• Experience in healthcare fraud is desired.
• Knowledge of Medicare is preferred.
• Certified Fraud Examiner certification is preferred.