Investigator Fraud Waste and Abuse

Investigator Fraud Waste and Abuse

Requirements

• High School Diploma or Equivalent (GED) – (Required)
• Minimum of 7 years – Relevant experience* (Required)
• Computer Literacy
• Critical Thinking
• Group Problem Solving
• Health Insurance
• Interpersonal Communication
• Waterfall Model

Responsibilities

• Conducts investigations of potential fraud, waste and abuse.
• Interviews members, providers, provider staff and other witnesses and experts. Proactively performs research using the internet, data analysis tools, and interviews to improve investigation development.
• Performs data mining and analysis to detect aberrancies and outliers in claims data. Provides case updates on progress of investigations to internal departments, committees and management.
• Establishes and maintains quality relationships with public officials, law enforcement and others to obtain assistance in conducting investigations.
• Provides proactive case development support to develop quality leads and cases received from a variety of sources including CMS, OIG, fraud alerts, and referrals from internal and external stakeholders.
• Utilizes knowledge of coding, the Health Plan benefits, provider contracts, Pennsylvania state regulations relevant to the Health Plan, and claims adjudication.
• Reports to Management potential issues identified that relate to the Health Plan Fraud and Abuse policy Prepares concise investigatory reports to support findings of potential fraud, waste and abuse.
• Documents all investigative work in tracking software. Conducts onsite provider audits and investigations, provide member and provider and employee education related to fraud, waste, and abuse.
• Supports legal proceedings as needed, including law enforcement subpoenas, data requests, preparation for civil or criminal actions.

Preferred Qualifications

• Certified Fraud Examiner
• Accredited HealthCare Fraud Investigator