SIU Fraud Investigator

About the role

Mass General Brigham Health Plan is a forward-thinking entity within the healthcare sector. As part of Mass General Brigham, we are committed to innovation and excellence, offering a range of services from patient care to research and community service. We seek to provide our members with innovative solutions that enhance access to care and coverage. Our employees are at the heart of this mission, working alongside some of the most accomplished professionals in healthcare.

Responsibilities

• Conducting confidential investigations of suspected fraud, waste & abuse (FWA) involving medical providers, plan members, or other entities or individuals.
• Data analysis, public records research, document review, and interviewing as part of investigative activities.
• Reviewing, interpreting, and applying payment policies, medical policies, provider manuals, benefits documents, national or local coverage determinations, and other applicable clinical practice parameters, regulations, or guidance.
• Obtaining investigative evidence through requests for medical and administrative documents and conducting interviews of providers, members, or other associated parties.
• Analyzing and interpreting multiple sources of data, including health insurance claims, financial transaction information, contract configurations, and other materials.
• Creating timely documentation, including investigative plans, case summaries, and interview reports.
• Staying updated with industry trends, particularly those related to fraud, waste, and abuse schemes.

Qualifications

• Bachelor's Degree in a related field required; experience can be considered in lieu of a degree.
• At least 5-7 years of experience conducting fraud, waste, and abuse investigations required.
• Strong, demonstrated track record of executing on time, on budget, and on scope.
• Strong aptitude for technology-based solutions.
• Excellent leadership skills and leadership track record.
• Ability to translate and communicate complex topics in a variety of forums.
• Excellent interpersonal skills.

Additional Job Details

(if applicable)

Working Conditions

This is a hybrid role requiring an on-site presence at the office in Assembly Row, Somerville roughly once per month. Remote Type: Hybrid. Work Location: 399 Revolution Drive. Scheduled Weekly Hours: 40. Employee Type: Regular. Work Shift: Day (United States of America).

Pay Range

$79,560.00 - $115,720.80/Annual. Grade 7.

Additional Information

At Mass General Brigham, we recognize and reward the unique value each team member brings to our organization. Our approach to determining base pay takes into account skills, relevant experience, education, certifications, and other essential factors. We offer a comprehensive benefits package, career advancement opportunities, differentials, premiums, and bonuses as applicable, and recognition programs designed to celebrate contributions and support professional growth. We are committed to equal opportunity and provide accommodations for individuals with disabilities.