Investigator, Special Investigative Unit-Nebraska

Job Summary

Essential Job Duties

• Develops leads and conducts preliminary assessments of FWA allegations.
• Conducts both preliminary and end-to-end investigations, including witness interviews, background checks, data analytics, contract and program regulation research, provider and member education, findings identification, communications development, recommendations, and preparation of overpayment identifications.
• Closes investigative cases within mandated periods.
• Completes on-site and desktop investigations, conducting medical record reviews and data analyses.
• Determines appropriateness of care and adherence to coding and billing guidelines.
• Produces audit reports for internal and external review.
• Coordinates with various internal customers to gather documentation pertinent to investigations.
• Detects potential FWA through aberrant coding and billing patterns using utilization review.
• Prepares appropriate FWA referrals to regulatory agencies and law enforcement.
• Documents case-related information accurately in the case management system.
• Prepares detailed referrals to state and/or federal regulatory and/or law enforcement agencies when FWA is identified.
• Renders provider education on appropriate practices (e.g., coding) based on national or local guidelines, contractual, and/or regulatory requirements.
• Interacts with regulatory and/or law enforcement agencies regarding case investigations.
• Prepares audit results letters to providers when overpayments are identified.
• Ensures compliance with applicable contractual requirements and federal and state regulations.
• Supports SIU in arbitrations, legal procedures, and settlements.
• Participates in Medicaid Fraud Control Unit (MFCU) meetings and roundtables on FWA case development and referrals.
• Works with other internal departments, including compliance, corporate legal counsel, and medical affairs, to achieve and maintain appropriate anti-fraud oversight.

Required Qualifications

• At least 2 years of investigative experience in the health care industry, or equivalent combination of relevant education and experience.
• Valid and unrestricted driver’s license.
• Proven investigatory skills including ability to organize, analyze, and effectively determine risk with corresponding solutions, and remain objective and separate facts from opinions.
• Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.
• Knowledge of managed care and Medicaid, Medicare, and Marketplace programs.
• Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.
• Understanding of datamining and use of data analytics to detect FWA.
• Ability to research and interpret regulatory requirements.
• Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels.
• Strong presentation skills with ability to create and deliver training, informational, and other types of programs.
• Strong logical, analytical, critical-thinking, and problem-solving skills.
• Strong sense of initiative, excellent follow-through, and persistence in locating and securing needed information.
• Fundamental understanding of audits and corrective actions.
• Ability to multi-task and operate effectively across geographic and functional boundaries.
• Detail-oriented, self-motivated, and able to meet tight deadlines.
• Ability to develop realistic, motivating goals and objectives, track progress, and adapt to changing priorities.
• Energetic and forward-thinking with high ethical standards and a professional image.
• Collaborative and team-oriented.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software program(s) proficiency.

Preferred Qualifications

• Experience in government programs (i.e., Medicare, Medicaid, Marketplace).
• Experience in FWA or related work.
• Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE).