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Special Investigator

Palm Beach Gardens, FL | Full Time
21 Days Ago

Job Description

The Investigator is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full range of products at the AmeriHealth Caritas Family of Companies (ACFC).   

Major Accountabilities:

  • Ensures compliance with all requirements related to Special Investigation Units and fraud, waste and abuse investigations.
  • Performance of data-mining activities to identify potential cases for investigation.
  • Performing sampling methodologies for medical record requests/reviews (e.g., OIG SVRS tool, Probe or random sampling).
  • Conducts investigations of potential  fraud, waste and/or abuse with a focus on thoroughness and attention to detail, quality, timeliness and cost control.
  • Conducts comprehensive interviews with providers, members and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.
  • Proactively performs research using the Internet, data analysis tools, etc., to analyze aberrant claims billing and practice patterns.
  • Analyzes data as part of the investigative process using available fraud detection software and corporate resources.
  • Represents ACFC in conducting settlement negotiations with providers, counsel and/or other associated parties.
  • Prepares and submits investigative reports covering all phases of the investigation.
  • Interprets and conveys highly technical information to others. 
  • Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations.

Education/ Experience:

  • Bachelor’s Degree preferred.
  • Valid driver’s license required
  • Ability to work independently with minimal supervision, and manage a high volume of assignments.
  • Strong verbal and written communication skills.
  • High degree of integrity and confidentiality required handling information that is considered personal and confidential.  
  • Analytical skills and ability to make deductions; logical and sequential thinker.
  • A minimum of 3-5 years experience conducting comprehensive health care fraud  investigations; interacting with state, federal and local law enforcement agencies.

Other Skills:  

  • Health care industry and/or Medicare/Medicaid/Pharmacy/Behavioral Health/Pharmacy Benefit Management knowledge required.
  • SIU and/or State Medicaid regulatory compliance work experience preferred.
  • Knowledge and  proficiency in claims adjudication standards & procedures preferred.
  • Solid knowledge of Medicaid, Medicare, and pharmacy benefit laws and requirements; federal, state, civil and criminal statutes.
  • Experience with decision support tools used for data analysis.
  • Advanced knowledge and experience working on various approaches to fraud, waste and abuse.
  • Working knowledge of Microsoft applications, especially Excel required.
  • Knowledge of available resources (internal and external) to assist in investigations.

Company Overview

  • Website
  • Headquarters PHILADELPHIA, PA
  • Size 3,000 - 7,500
  • Founded 1983
  • Type
  • Revenue $5B - $10B
  • Industry Healthcare
  • About amerihealth caritas health plan
  • At AmeriHealth Caritas, care is the heart of our work. That means that every day we put our members and their families first. We work to improve not only their health, but also the economic and social issues that can act as a barrier to proper care ' the social determinants of health that are estimated to account for 70 percent of avoidable mortality in the U.S. alone. Through our Next Generation Model of Care, we emphasize preventive care, health maintenance, and community outreach programs with a strong focus on ensuring members have access to food, housing, utilities, and other basic necess ... ities. Our mission To help people get care, stay well, and build healthy communities. We have special concern for those who are poor. Our vision Our goal is to develop strategic partnerships and build accessible, flexible health systems across the nation. Moving forward as health care evolves, we will continue to ensure the greatest level of care at maximum value for members, providers, and governments. Ensuring equal access to health care through health equity and health literacy More than 77 million adults have basic or below basic health literacy ' or the ability to understand the basic health services and instructions they receive. Even more can't access the care they need because of social and cultural disparities. Low health literacy costs the U.S. billions of dollars every year and impacts the quality of care millions of Americans receive. In the spirit of our mission, our whole-person model of care leverages Culturally and Linguistically Appropriate Services (CLAS) standards and strong community partnerships. Through community outreach, collaboration with providers and their staff, and 24/7 access to interpretation services, we help to ensure each of our members gets the appropriate, unique care and services they need and deserve. More

Skills for Special Investigator

The job skills required for Special Investigator include Law Enforcement, Written Communication, Confidentiality, Medicaid, Attention to Detail,and Data Mining etc. Having related job skills and expertise will give you an advantage when applying to be a Special Investigator. That makes you unique and can impact how much salary you can get paid. Below are job openings related to skills required by Special Investigator. Select any job title you are interested in and start to search job requirements.

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Career Path for Special Investigator

The following is the career advancement route for Special Investigator positions, which can be used as a reference in future career path planning. As a Special Investigator, it can be promoted into senior positions as a Campus Police Officer that are expected to handle more key tasks, people in this role will get a higher salary paid than an ordinary Special Investigator. You can explore the career advancement for a Special Investigator below and select your interested title to get hiring information.