Senior Investigator

Primary Responsibilities

• Assess complaints of alleged misconduct received within the Company
• Investigate medium to highly complex cases of fraud, waste and abuse
• 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 summaries of the findings
• Participate in settlement negotiations and/or produce investigative materials in support of the latter
• Communicate effectively, including written and verbal forms of communication
• Develop goals and objectives, track progress and adapt to changing priorities
• Collect, collate, analyze and interpret data relating to fraud, waste and abuse referrals
• Ensure compliance of applicable federal/state regulations or contractual obligations
• Report suspected fraud, waste and abuse 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 SIU leadership, to include attendance at workgroups or regulatory meetings

Requirements

• Bachelor's degree OR Associate's degree plus two years of equivalent work experience with healthcare related employment
• Intermediate level of knowledge in health care fraud, waste and abuse (FWA)
• Intermediate level of knowledge in state or federal regulatory FWA requirements
• Intermediate level of knowledge analyzing data to identify fraud, waste and abuse trends
• Intermediate level of proficiency in Microsoft Excel and Word
• Ability to travel up to 25% of the time
• Must be willing and able to participate in legal proceedings, arbitration, and depositions at the direction of management
• Must reside in California, Texas, Georgia, New York, or Florida
• Intermediate level of skills in developing investigative strategies
• Active affiliations: National Health Care Anti-Fraud Association (NHCAA), Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Medical Laboratory Technician (MLT)