What are the responsibilities and job description for the Investigator II position at HMSA?
Employment Type
Full-time
Exempt or Non-Exempt
Exempt
Job Summary
Note: Individuals typically begin between the minimum to middle of the pay range
Responsible for the intake, review and documentation of Fraud, Waste and Abuse (FWA) allegations referred to the Special Investigations Unit (SIU). Initiate and drive pro-active FWA cases through to resolution. Provides recommendations to close inquiries or open investigative cases for FWA referrals. Resolve complex FWA investigative cases via in-depth research and analysis, interviews, onsite audits and other investigative techniques through the recovery of healthcare dollars and allocation back to applicable entities. Manages regulatory notices, case summaries and collaborates with external entities, including but not limited to federal, state and law enforcement. Collaborate with vendors on FWA allegations and cases impacting HMSA. Lead on-site provider audits for the purposes of FWA investigations and internal audits as applicable.
Minimum Qualifications
Full-time
Exempt or Non-Exempt
Exempt
Job Summary
- Hybrid Work Environment - Must reside in Hawaii**
Note: Individuals typically begin between the minimum to middle of the pay range
Responsible for the intake, review and documentation of Fraud, Waste and Abuse (FWA) allegations referred to the Special Investigations Unit (SIU). Initiate and drive pro-active FWA cases through to resolution. Provides recommendations to close inquiries or open investigative cases for FWA referrals. Resolve complex FWA investigative cases via in-depth research and analysis, interviews, onsite audits and other investigative techniques through the recovery of healthcare dollars and allocation back to applicable entities. Manages regulatory notices, case summaries and collaborates with external entities, including but not limited to federal, state and law enforcement. Collaborate with vendors on FWA allegations and cases impacting HMSA. Lead on-site provider audits for the purposes of FWA investigations and internal audits as applicable.
Minimum Qualifications
- Bachelor's degree and two years of related work experience; or equivalent combination of education and related work experience.
- Fundamental knowledge/awareness of Fraud, Waste and Abuse.
- Strong oral and written communication skills.
- Knowledge of health care investigations.
- Intermediate working knowledge of Microsoft Word, Excel, PowerPoint, and Outlook.
- SIU case investigation management, resolution and prevention:
- Manage complex FWA case investigations, collaborate with federal, state and law enforcement entities, and provide applicable notifications as required.
- Conduct pro-active FWA case investigations and resolutions.
- Maintain extensive documentation and evidence for SIU cases.
- Recommend and implement preventive measures to combat FWA schemes including, but not limited to provider education, policies, claims edits and payment suspensions.
- Conduct and lead on-site provider audits and interviews to support complex FWA case investigations.
- Manage the recovery, allocation and documentation of health plan funds resulting from FWA findings.
- Support SIU Operations:
- Create and maintain internal policies and procedures, workflows and presentations and present as needed to internal and external entities.
- Coordinate and manage regulatory audit requests and RFIs from law enforcement and federal and state entities.
- Represent SIU at cross functional workgroups and meetings and present case recommendations and preventive solutions to Management and other applicable business areas including, but not limited to Legal, Medical Management, Provider Operations and Claims Operations.
- Provide operational oversight to SIU Vendors with delegated FWA functions.
- Create and/or refresh and present SIU training to HMSA employees, employer groups, vendors and other business areas as needed.
- SIU allegation intake and management:
- Manage the intake, documentation and resolution of FWA referrals to SIU.
- Coordinate with internal and external partners on FWA allegations.
- Assess needs, make recommendations and complete timely reviews in accordance with all regulatory requirements.
- Perform all other miscellaneous responsibilities and duties as assigned or directed.
Salary : $53,000 - $99,000