Responsibilities:

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.