Investigator II

About the role

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone.

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.

Responsibilities

• Lead moderately complex to complex behavioral health 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.
• Familiarity with and/or experience in Applied Behavior Analysis (ABA); Board Certified Behavior Analyst (BCBA) certification preferred.
• 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 overpayments, 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.

Qualifications

• Certified Professional Coder (“CPC”); Certified Fraud Examiner (“CFE”) designation a plus.
• Bachelor’s degree; preferably in a clinical or scientific field, business, accounting, computer science, or criminal justice.
• 3-5 years’ related experience in health insurance and/or fraud investigations; experience in audits/investigations including experience drafting and distributing summary findings notices to providers or other entities preferred.

Skills

• Ability to produce clear, concise, and well-organized documents.
• Resilient, collaborative, flexible, innovative.

Working Conditions and Additional Requirements

Must be able to work under normal office conditions and work from home as required. May be required to attend meetings at other company locations or other external meetings. Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations. May be required to work additional hours beyond standard work schedule.

Pay

Salary Range $80,741.22 -$121,111.82

Benefits

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health