Fraud Investigator II

About the Role

The Fraud Investigator II plays a crucial role in combating fraud, waste, and abuse (FWA) within the Medicaid program. This position involves extensive research to identify industry trends and patterns targeting aberrant billing practices. The Investigator II collaborates on complex case reviews, performs data mining and analysis, and assists in recoveries. With increasing independence, the role serves as a senior investigator, coaching others on techniques to uncover provider schemes based on federal and state regulations.

Responsibilities

• Apply in-depth knowledge of federal and state regulations and healthcare industry standards.
• Conduct independent data mining and analysis using claims data to detect aberrancies, outliers, and trends for potential cases.
• Develop algorithms, queries, and reports to identify potential FWA activity.
• Analyze member records and claims data to ensure compliance with regulations, contracts, and policy manuals.
• Develop reports of investigative findings, compile case file documentation, calculate overpayments, and issue findings in accordance with agency policies.
• Document work performed and audit results based on predetermined standards and guidelines.
• Communicate with providers regarding audit findings, recoveries, and educational feedback.
• Identify and recommend policy, procedure, and system changes to enhance investigative outcomes.
• Determine compliance with Medicaid regulations by examining records.
• Assist Investigator I staff in recognizing fraudulent patterns for complex cases.
• Serve as a resource for departments to research and resolve integrity inquiries.
• Update internal management staff on investigation progress and recommend further initiatives, such as new algorithms.
• Create, maintain, and manage cases within the tracking system to ensure accuracy and timeliness.
• Perform other duties as needed.

Requirements

• A Bachelor’s degree in Business Administration, Finance, Public Health, or a related field; or equivalent years of experience.
• 5-7 years of related experience in fraud examination, healthcare, business, finance, or a related field, with at least 2 years of experience conducting data mining in the healthcare insurance industry and claims-related experience.
• Knowledge of coding, reimbursement, and claims processing policies.
• Knowledge of the principles and practices of medical auditing.
• Strong analytical, qualitative, and problem-solving skills with the ability to identify root causes and implement solutions.
• Knowledge of laws and regulations related to fraud and fraud investigations.
• Proven track record of producing high-quality work with attention to detail.
• Ability to multi-task, establish priorities, and work independently to achieve objectives.
• Ability to function effectively under pressure.
• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint, and Access).
• Excellent customer service skills with the ability to interact professionally with providers, third-party payers, and staff.
• Strong interpersonal skills to work in a fast-paced environment, both as a team member and independently.
• Strong oral and written communication skills, including internal and external presentations.

Preferred Qualifications

• Certifications or licensure such as CPC or CPMA.
• Advanced SQL and Microsoft Excel skills.
• Knowledge of state and federal regulations as they apply to public assistance programs.
• Strong decision-making skills with the ability to investigate and weigh alternatives.
• Creative thinking skills to ask "bigger-picture" questions that lead to process and team improvements.

Schedule

Position requires travel to the office in Westborough an average of two times per month.