Healthcare Fraud Investigator

Job Description Summary:

Independently performs in-depth evaluation and makes field level judgments related to investigations of potential Medicare fraud, waste and abuse investigations or cases that meet established criteria for referral to the Centers for Medicare & Medicaid for administrative action or to the OIG for criminal action.

Duties/Responsibilities: • Utilizes leads provided by the team and referrals from government and private agencies, works with the team to prioritize complaints for investigation, and then investigates, conducts interviews and reviews information to make potential fraud determination • Determines investigation or case appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria • Based on contract requirements, may refer potential adverse decisions to the Lead Investigator/Manager/Medical Director or designee • Conducts interviews of witnesses, informants, and subject area experts and targets of investigations • Identifies, collects, preserves, analyzes and summarizes evidence, examining records, verifying authenticity of documents, may provide information to support the preparation of attestations/referrals or supervising the preparation of attestations/referrals as needed • Drafts investigation reports, evaluates investigation reports, and promotes effective and efficient investigations • Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting investigation or case findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies • Testifies at various legal proceedings as necessary • Identifies opportunities to improve processes and procedures • Has the responsibility and authority to perform their job and provide customer satisfaction • Other duties may be assigned.

Required qualifications/skills:
• A Bachelor's Degree or one or more of the following:
• Certification in an applicable program such as Certified Fraud Examiner or Accredited Healthcare Anti-Fraud Investigator Certification
• Successful completion of a law enforcement academy
• Experience in health care fraud investigation/detection
• Demonstrated expertise in reviewing, analyzing, and making appropriate decisions.
• Prior successful experience with CMS and OIG/FBI or similar agencies
• Ability to work independently with minimal supervision
• State Medicaid experience

Preferred qualifications/skills:
• Certified Fraud Examiner (CFE) or Accredited Healthcare Anti-Fraud Investigator preferred
• Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data
• Problem Solving – Gathers and analyses information skillfully; Identifies and resolves problems
• Written Communication - Writes clearly and informatively; Able to read and interpret written information
• Judgment - Supports and explains reasoning for decisions
• Language - Ability to read, analyze, and interpret technical procedures, review documents, or contract regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public
• Mathematical Skills - Ability to apply basic mathematical functions
• Reasoning Ability - Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
• Computer - To perform this job successfully, an individual must have knowledge of office software and the internet to meet contract deliverables. Utilizes required data entry and reporting systems, including advanced features.
• Ability to communicate effectively with all members of the team to which he/she is assigned
• Ability to grasp and adapt to changes in procedure and process
• Ability to effectively resolve complex issues
• Ability to mentor other associates
• Ability to appropriately handle information and documents containing PHI

Supervisory Responsibilities: • None

Other:
• Place of performance preference is remote with some requirements to work in the office in Houston, TX.
• While working from home, a broadband internet connection is required.
• The majority of this work is done in the field (30% or more) necessitating frequent use of personal or rental vehicle for travel in areas not normally served by public transportation
• Periodic overnight travel for periods of 1-5 days is required
• Travel is reimbursable via GSA Standards

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