Principal Investigator

About the role

The Principal Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste, and abuse. The role involves investigating highly complex cases, utilizing claims data, applicable guidelines, and other sources of information to identify aberrant billing practices and patterns. The role also includes assessing complaints of alleged misconduct, detecting fraudulent activity, and reporting suspected fraud to appropriate authorities.

Responsibilities

• Investigate highly complex cases of fraud, waste, and abuse (FWA)
• Demonstrated ability to think critically and analytically when evaluating complex healthcare data and documents
• Skilled in managing multiple cases with competing deadlines in a fast-paced environment
• Able to organize and synthesize large volumes of information
• Assess complaints of alleged misconduct received within the Company
• Detect fraudulent activity by members, providers, employees, and other parties against the Company
• Develop and deploy the most effective and efficient investigative strategy for each investigation
• Maintain accurate, current, and thorough case information in the Special Investigations Unit's (SIU's) case tracking system
• Collect and secure documentation or evidence and prepare detailed and defensible summaries of the findings
• Participate in settlement negotiations and/or produce investigative materials in support of
• Collect, collate, analyze, and interpret data relating to FWA referrals
• Ensure compliance of applicable federal/state regulations or contractual obligations
• Report suspected FWA to appropriate federal or state government regulators
• Comply with goals, policies, procedures, and strategic plans as delegated by SIU leadership
• Collaborate with state/federal partners, at the discretion of leadership, to include attendance at workgroups or regulatory meetings

Qualifications

• Bachelor's degree
• 5+ years of experience working in a government, legal, healthcare, managed care and/or health insurance environment in a regulatory, privacy or compliance/investigative role
• Advanced level of knowledge in health care FWA
• Advanced level of knowledge in state or federal regulatory FWA requirements
• Advanced level of knowledge analyzing data to identify FWA trends
• Advanced level of proficiency in Microsoft Excel and Word
• Ability to travel up to 25%
• Demonstrated ability to participate in legal proceedings, arbitration, and depositions at the direction of management

Preferred Qualifications

• Active affiliations: National Health Care Anti-Fraud Association (NHCAA)
• Accredited Health Care Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)
• CPT & ICD Coding experience
• Specialized knowledge/training in healthcare FWA investigations
• Experience working with attorneys or government agencies
• Demonstrated intermediate level of knowledge in health care policies, procedures, and documentation standards
• Demonstrated intermediate level of skills in developing investigative strategies

Pay and Benefits

The salary for this role will range from $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable. In addition to your salary, we offer benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements).

Equal Opportunity Employer

We are committed to providing equal employment opportunities for all individuals without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

Environmental Stewardship

We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.