Investigator Fraud Waste and Abuse, Geisinger Health Plan

• 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

Work is typically performed in an office environment. Travel may be required. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

This posting reflects an opening for Investigator Fraud Waste and Abuse and we are seeking candidates for that position. Geisinger reserves the right to consider applicants for higher levels of this role to include Investigator II Fraud Waste and Abuse based on their skills, qualifications, and experience. We encourage all qualified individuals to apply.

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Qualifications:

*Relevant experience may be a combination of related work experience and degree obtained (Associate’s Degree = 2 years; Bachelor’s Degree = 4 years).