The Investigator, Special Investigations Unit (SIU) is a key contributor to the Plan’s member and provider fraud, waste, and abuse (FWA) detection, investigation, remediation, and prevention efforts. The Investigator utilizes preliminary recommendations provided by the SIU Data Analyst to develop, conduct, resolve, document, and report on investigations of tips, allegations, or data mining output that suggests potentially fraudulent or abusive behavior. The Investigator’s scope of work may range from independent evaluation of preliminary information to on-site audit to participation in Federal or State prosecution of a case.

Key Functions/Responsibilities:

• Receives cases triaged to the SIU from the Data Analyst, SIU, based on preliminary issue evaluation, priority, and approval of the Manager, SIU.
• Initiates case portfolio initially including Data Analyst’s findings; over the course of the investigation, expands portfolio to include such documentation as relevant Plan policies and procedures, member and/or provider publications (e.g., Evidence of Coverage or contracts), medical records and audit findings, interview records, etc.
• Reviews Data Analyst’s preliminary findings and requests pertinent additional data from the applicable parties including, but not limited to, the Data Analyst, SIU, or Contracting, Claims, Pharmacy, Provider Relations, Business Integration, and/or Customer Care departments.
• Determines course of appropriate action based on line of business, severity of issue, and Plan exposure.
• Collaborates with SIU Manager and/or Data Analyst to identify audit sample, either random or based on another approved methodology.
• Conducts investigation including comprehensive review of any and/or all portfolio documentation and State-approved, where required, on-site or desk medical record review and/or member or provider interviews.
• Creates detailed investigation report, including follow-up or remedial action recommendations, per department protocol and presents to department management.
• Drafts preliminary investigation results documents for submission to provider or potential response to member.
• Drafts Corrective Action Plan, where appropriate, and submits to SIU Manager for approval.
• Coordinates with Provider Audit, Claims, Business Integration, Contracting, Compliance and/or Provider Relations staff when remedial actions such as pre-payment review, payment suspension, overpayment recovery, etc. dictate.
• Updates department FWA database at prescribed intervals and per department standards.
• As requested, participates in internal and/or external FWA-related information sharing sessions which may include receiving and providing secure data pursuant to contractual requirements.
• Prepares summary and/or detailed reports on investigation findings for referral to Federal and state agencies which may include but are not limited to state Medicaid agencies, Medicaid Fraud Control Units, the Attorney General’s Office, the Department of Insurance, and local law enforcement.
• Assists with FWA training for internal Health Plan staff.
• Collaborates with department management on the data mining function including, but not limited to, specific activities and output necessary to support Investigator’s activities.
• Meets all production deadlines.
• Ensures accuracy and quality of work product by adhering to department’s data validation guidelines.
• Regular and reliable attendance is an essential function of the position.

Qualifications:

Education:

• Bachelor’s degree in Health Information Management, Health Care Administration, Nursing or Other Clinical Field, Public Health, Criminal Justice, Law Enforcement or other related field; an equivalent combination of education, training, and experience may be considered

Preferred/Desirable:

• Advanced degree in an above noted area

Experience:

• Three to five years’ experience in a health care payer setting
• Minimum of three years’ experience in a health care fraud control setting

Preferred/Desirable:

• Three years’ experience in the Managed Care industry preferred; two years’ experience in Medicaid Managed Care highly preferred
• Two years’ experience in a Medicaid or Medicaid Managed Care fraud detection unit (eg, Special Investigations/Program Integrity Unit, Recovery Audit Contractor, Medicaid Fraud Control Unit) highly preferred

Certification/Conditions of Employment:

• National Health Care Anti-Fraud Association certification (AHFI), Certified Fraud Examiner (CFE), or America’s Health Insurance Plans Health Care Anti-Fraud Associate (HCAFA) designation
• Pre-employment background check

Preferred/Desirable:

• Health care coding certification (CPC or CCS) highly preferred

Competencies, Skills, and Attributes:

• Demonstrated proficiency with Microsoft Office products
• Time management skills necessary to meet established deadlines in a fast-paced environment, including the ability to re-prioritize tasks as workload and time constraints dictate
• Strong verbal and written communication skills with the ability to clearly articulate thoughts, ideas, processes and requirements to both internal and external audiences and in potentially contentious situations
• Attention to detail with excellent proof reading and editing skills
• Customer service skills with the ability to interact professionally and effectively with a wide variety of providers, third party payers, and staff from all departments within and outside the Plan
• Organization and analytical skills necessary to aggregate potentially disparate information from multiple sources
• Strong problem solving skills, including with the ability to determine root causes and to define workable solutions
• Ability to weigh alternatives and select the most appropriate course of action, given the individual circumstances of a case
• Creative thinking skills that allow one to ask the bigger-picture questions that lead to future improvements/gains
• Proven ability to maintain objectivity and the utmost confidentiality

Working Conditions and Physical Effort:

• Work is normally performed in a typical interior/office work environment.
• No or very limited physical effort required. No or very limited exposure to physical risk.
• Limited travel is required.