Special Investigations Unit Investigator

This position conducts healthcare fraud, waste, and abuse investigations as a member of the Special Investigations Unit (SIU) within the Compliance Department. The SIU Investigator is responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse (FWA). The SIU Investigator is also responsible for recognizing and adhering to national and local coding and billing guidelines to maintain coding accuracy and excellence. The position may also work with other internal departments, Corporate Compliance, Corporate Legal Counsel, and Medical Officers in order to achieve and maintain appropriate anti-fraud oversight.

Investigations are primarily conducted through data analysis (a high level of proficiency with Excel is required). This is not a physical investigator role.

Position may also evaluate the adequacy and effectiveness of internal control, risk management, and governance processes for Hometown Health and Medicare Advantage products.

• Assess complaints of alleged misconduct received within the Company.

• Responsible for developing leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence.

• Proactively identifies trends and aberrant activity to generate leads for fraud investigations and analyzes claims data to detect fraudulent activity.

• Conducts both preliminary assessments of FWA allegations, and end to end full investigations, including but not limited to witness interviews, background checks, data analytics to identify outlier billing behavior, contract and program regulation research, provider and member education, findings identification and communications development, and recommendations and preparation of overpayment identifications and closure of investigative cases.

• Completes investigations within the mandated period required by either state and/or federal contracts and/or regulations and/or company policy.

• Conducts low to medium, and extensive investigations, including reviews of medical records and data analysis, and makes determinations as to whether the investigation and/or audit identified potential fraud, waste, or abuse.

• Coordinates with various internal customers (e.g., Provider Network Services, Health Utilization Management, Member Services, Claims) to gather documentation pertinent to investigations.

• Prepares appropriate FWA referrals to regulatory agencies and law enforcement.

• Maintains accurate, current, and thorough case information in the SIU case tracking system. The position also entails producing audit reports for internal and external review.

• Interacts with regulatory and/or law enforcement agencies regarding case investigations.

• Prepares audit results letters to providers when overpayments are identified.

• Comply with goals, policies, procedures, and strategic plans as delegated by SIU leadership.

• Prepares Compliance Committee reports.

• Performs operational and Fraud, Waste, and Abuse audits; special projects, as requested; and internal control and information systems evaluations at the direction of leadership.

This position must be objective and independent of the activity being reviewed. It is authorized to have free and unrestricted access to organization functions, records, property, and personnel.

Knowledge, Skills, and Abilities:

• Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions; ability to remain objective and separate facts from opinions.

• Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.

• Knowledge of Managed Care and Medicare programs as well as Marketplace.

• Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.

• Understanding of datamining and use of data analytics to detect fraud, waste, and abuse.

• Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels.

• Excellent oral and written communication skills; presentation skills with ability to create and deliver training, informational and other types of programs.

• Strong logical, analytical, critical thinking and problem-solving skills.

• Initiative, excellent follow-through, persistence in locating and securing needed information.

• Fundamental understanding of audits and corrective actions.

This position does not provide direct patient care.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Name

Description

Education:

Must have working-level knowledge of the English language, including reading, writing, and speaking English. Requires B.S. or B.A. in a related field or equivalent combination of education and experience.

Experience:

2+ years of experience in health care fraud, waste, and abuse

License(s):

None

Certification(s):

Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) or Certified Professional Coder (CPC); or the ability to obtain within 1 year of hire.

Computer / Typing:

Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel, and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.