Fraud Investigator

Responsibilities:

• Conduct confidential investigations of all assigned cases: collect support evidence, data analysis, identify overpayments, apply industry guidelines, and communicate findings to Assistant Director
• Analyze and interpret patient medical records pertaining to fraud and abuse investigations and determines appropriateness of billing and reimbursement.
• Prepare and maintain investigative case files including the preparation of reports and indexing of all evidence.
• Participate in various meetings (e.g., committees and attorneys) involving case strategies development, provider negotiations, information sharing, etc.
• Manage the recovery of overpayments, issue refund demand letters, settlement agreements, administrative action letters, repayment plans; track suspensions and withholding activities.
• Prepare Monthly Management, Case Tracking, and Recovery/Collections reports.
• Conduct research to develop supporting evidence.
• Conduct comprehensive interviews with providers, members, and witnesses to obtain information that is generally acceptable under the civil rules of evidence.
• Utilize expertise of outside vendors to coordinate outsourced anti-fraud services (e.g., maintenance of the fraud detection software/database, expert opinions, medical review, onsite facility audit, fraud detection data analysis etc.)
• Develop communications to effectively communicate with providers, vendors etc.
• Attend internal and external training seminars to maintain a high level of professional excellence, and knowledge of industry standards and trends through training.

Qualifications:

• Bachelor’s Degree in Criminal Justice or related field required
• Minimum of two (2) years experience conducting or assisting in fraud investigations or the equivalent combination of education, experience, and training that provides the required knowledge, skills, and abilities for the position.
• Knowledge of the business operations of an ERISA/Taft-Hartley Plan (preferred, but not required);
• Proven track record in the preparation and maintaining of investigative case files to include the preparation of reports and indexing of all evidence.
• Excellent investigative, technical, analytical, and/or project management skills.
• Ability to maintain the highest level of confidentiality.
• Proficiency in Microsoft Office applications (i.e., Word, Excel, PowerPoint and Outlook) and internal or vendor provided case tracking software.
• Knowledge of performing data analysis and documenting findings in a spreadsheet.
• Strategic planning, analytical and problem-solving skills; excellent organizational, record keeping, operations management and time management skills; excellent interpersonal and communications skills – oral, written, and listening
• Excellent report writing skills