Senior Investigator - Pre-Pay (Healthcare FWA)

Responsibilities

• Identify, investigate, analyze and evaluate instances of potential fraud, waste, and abuse.
• Proactively monitors provider activity to identify patterns, anomalies, and emerging trends that may warrant further investigation.
• Utilizes data analytics, claims review, and industry intelligence to detect potential fraud, waste, abuse, or non-compliance.
• Leverages claims data, dashboards, and predictive models to identify providers exhibiting atypical billing patterns or potential fraud, waste, and abuse.
• Analyze information gathered by investigation and report findings and recommendations as a written summary and/or presentation.
• Conducts investigation-related training.
• Supports legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions.

Qualifications

• Bachelor’s Degree in related discipline, or the equivalent combination of education, professional training and work experience.
• 5-8 years of related healthcare FWA investigative experience.
• Experience in proactive data mining.
• Advanced level skills in Excel required.
• Experience using Cotiviti FWA tools (preferred) - Sentinel, Commander, and/or Informant (Stars Solutions).
• Excellent verbal and written communication skills.
• Strong listening and observation skills.
• Attention to detail and high level of accuracy.
• Effective organizational and prioritization skills with multi-tasking ability.

Preferred Certifications

• Accredited Healthcare Fraud Investigator (AHFI)
• Certified Fraud Specialist (CFS)
• Certified Fraud Examiner (CFE)
• Certified Forensic Interviewer (CFI)
• Certified in Healthcare Compliance (CHC)