Fraud Investigator(SIU)

Job Title: Manager Special Investigations Unit

Location: (Remote)

Duration: 3 months (possible extension)

Position Overview:

Responsible for the oversight of the Special Investigations Unit (SIU) and Fraud, Waste & Abuse (FWA) Program in compliance with contractual and regulatory requirements. Oversees case management, case investigation, overpayment recoveries, reporting of investigations to regulatory agencies; responds to government requests for information related to FWA; facilitates compliance with state and federal FWA requirements; develops and maintains employee education; and identifies new recovery opportunities, goals and sound practices.

Key Responsibilities:

• Coordinates with subcontractors on overseeing investigations of Fraud, Waste & Abuse (FWA).
• Manages a large fraud investigation caseload and investigates allegations relating to potential health care fraud perpetrated by Medicaid and commercial providers, vendors and enrolees.
• Provides internal and external case updates on progression of investigations in coordination with SIU team members and other departments, including recommendations on further action and/or resolution, as needed.
• Continually interfaces with members, vendors, pharmacies, providers and other third parties via telephone, e-mail, and on-site visits as needed to identify, further, and conclude ongoing investigations.
• Implements processes and procedures to prevent, detect, investigate and report FWA to appropriate regulatory agencies.
• Provides inter-departmental input regarding controls for preventing and monitoring FWA issues.
• Proactively identifies trends and aberrant activity to generate leads for FWA investigations.
• Performs special assignments related to FWA as assigned by the Director of Controls and Compliance.
• Special Investigations Unit (SIU) experience with a Health Plan and understands the components and functions of an SIU.

Skills:

• Strong analytical and research skills. Proficient in researching information and identifying information resources.
• Exercises independent judgement and uses available resources and technology in developing evidence and supporting allegations of fraud, waste and abuse.
• Knowledge of medical terminology and/or experience with CPT codes, and ICD-9, ICD-10 coding.
• Knowledge of suspected FWA trends and matters of interest to law enforcement and regulators.
• Strong communication and customer service skills.

Required Experience & Qualifications:

• H.S. Diploma or GED OR Bachelor's Degree
• 8 years OF experience in fraud, waste & abuse (FWA) investigations or special investigations unit (SIU)
• 1 year experience working with Medicaid.

Certificate Required:

• CPA - Cert-Cert Public Accountant- Relevant state board of public accountancy.
• CFA - Certified Fraud Examiner- Association of Certified Fraud Examiners.
• AHFI - Accredited Health Care Fraud Investigator - NHCAA National Health Care Anti-Fraud Association.
• INT-POPC Intermediate Peace Officer Proficiency Certificate- Intermediate Peace Officer Proficiency Certificate.